Cardiology Case Study 11

Cardiology

TAPE 8B, Report 11

EMERGENCY ROOM REPORT

This 65-year-old man is admitted to the hospital drunken, but with multiple ventricular premature beats; this is the primary reason.  He fell backward and seemed to be fading in and out, and it was uncertain whether it was due to drinking or something else, and he was started on lidocaine, and his rhythm has been under control.

History is impossible because he denies everything.  He is fine, no problem, and so it is difficult to know what problems he has.  His son is with him and says his drinking has been a problem for a long while.  At that time a diagnosis of hepatic insufficiency with cirrhosis secondary to alcohol abuse, prostatic hypertrophy, chronic obstructive lung disease, and hiatal hernia, all these diagnoses were made.

PHYSICAL EXAMINATION

Examination shows a man with a few minor abrasions, who is very talkative but does not seem to be in any great distress.  Eyes:  Pupils are too small to see.  Ears show wax.  Nose and throat are normal.  I did not detect any jaundice, but I did not specifically look for it.  I felt no lymph nodes.  The lungs are clear to auscultation.  I did not take a blood pressure.  The heart rate was 84.  The rhythm was regular.  I heard no diagnostic murmurs.  The abdomen was soft.  I felt no masses or organs.  Genitalia appeared normal.  The patient had no edema, but he was very dirty.  I thought I felt peripheral pulses.  He was not relaxed enough to check reflexes.

IMPRESSION

1. Ventricular arrhythmia.

2. Alcoholism.

3. History of hepatic insufficiency.

FOOTNOTE

Line 17.  At that time was deleted as it was repeated in the sentence.

Line 22.  The heading Physical Examination was added.

Lines 35-38.  The diagnoses were enumerated in the Impression.