Ophthalmology Case Study

HISTORY
Patient is a 68-year-old female who was involved in a motor vehicle accident in Marianna, Florida on Sunday, December 30.  She evidently hit a guardrail, flipped the car twice, and an 18-wheeler hit them.  The car was destroyed.  She was evidently cut out of the roof of the car, she and her husband, and transported to a local hospital, Jackson Hospital, where they sewed them up, cleaned their cuts up.  They put multiple staples in her head.  Did a CT scan of her neck, back, and thoracic spine.  There were obvious thoracic fractures they identified.  Cervical, they were not sure, so she was transferred to Flowers Hospital the same afternoon to get ophthalmological consult along with pulmonary and neurology.  They winded up getting on neurosurgeon's service and was taken care of.  They really wanted to come back home.  Family was over there visiting but they just were concerned because she just was not getting much better, and she was having a breathing problems.  They called pulmonology in, according to my phone call to neurosurgery over there today prior to discharge, did an x-ray and some tests and said she has hypoxia secondary to atelectasis and a small right pleural effusion.  She was on Lortab.  They had been getting IV antibiotics while there for the last 3 days.  All these records have not been totally reviewed at this time.  Last record I get was saturation was 88% on room air, 93% on 3 L, and laboratory data was done over there, which showed everything had been stable.  She supposedly got a CT scan of her C-spine, which shows some degenerative changes.  There is a questionable nondisplaced hairline fracture in the right lamina of C2, which is why she is transferred to Flowers.  This was all done in Jackson Hospital.  She had a portable chest x-ray, which showed cardiomegaly, otherwise unremarkable.  No rib fractures identified.  She had a CT scan of the head, which showed no midline shift.  Scalp lacerations were identified.  The bony cranium was intact.  There were no fractures in the hand or arm.  I cannot find the CT scan report of the rest of her thoracic spine and that is what I keep looking for, but they did CT of her head, sinuses, facial bones, even a CT scan of her abdomen and nothing was ruptured.  Patient desired to come back home, but with still being on O2, they recommended transfer to another acute hospital.  Neurosurgeon called me.  We elected to take the patient in transfer.  She is a patient here in my clinic, and we will get a spine surgeon involved, because they wanted her thoracic spine evaluated and probably repeat her C-spine films, according to neurosurgeon, although he took the brace off.

PAST MEDICAL HISTORY

She has no known allergies.  She had her gallbladder out 40-plus years ago as well as appendix at same time.  She had a shoulder surgery 10 years ago for frozen shoulder.  She has had high blood pressure for about 10 years ago.  She has a diagnosis of sarcoid years ago, but has not had a flare-up since.  She also was recently diagnosed with Cameron ulcers and underwent Nissen fundoplication, which was very successful and she has not had any reflux and currently has been maintained on just Norvasc 5 milligrams a day for blood pressure and Lexapro 10 milligrams a day for anxiety, and this was situational depression with family issues.

FAMILY HISTORY

Mother died at 97.  Dad passed away with heart disease at 78.  She has been married for 46-plus years.  She does not smoke.  She has 2 children.

PHYSICAL EXAMINATION

GENERAL:  When I see patient lying in the bed, she is bruised and battered.  She has multiple staples in her scalp.  On the left, there are multiple ones.  On the right, there are 5 to 6.  She has small abrasions throughout and marked ecchymosed.  She is complaining of like chest wall pain, mainly when she moves over or takes a deep breath, like somebody just putting a knife through her.  Her back is sore at all times and the brace seems to be making her chest pain worse.

ENT EXAM:  Her pupils are equal, round, and reactive to light.  She is talking but they said she has been a little groggy, but we gave her some Demerol and Phenergan when she got here from the ambulance ride because she was in intense pain.

CHEST:  She has bilateral breath sounds, slightly diminished in the bases, but I do not hear any wheezes.

CARDIAC:  Her cardiac examination is regular.

ABDOMEN:  Soft.  She has positive bowel sounds.

EXTREMITIES:  She has multiple contusions, raised, but really there is no edema.  She has TED hose in place.

RECTAL:  Did not do at this time.

GYNECOLOGIC:  Did not do at this time.

LABORATORY DATA

She had a CMP, which showed slightly low potassium of 3.5, albumin a little bit low at 3.  Her H and H was 10.8 and 33.1.  I am sure this is secondary to blood loss from her scalp lesion because evidently she had a lot of bleeding and she still has some dried blood.

ADMISSION DIAGNOSES

1.            Motor vehicle accident with multiple trauma patients.  She evidently has known thoracic fractures, possible cervical fractures.  This is going to be reexamined today because the neurosurgeon stated it was ruled out in Dothan, but we will need C-spine films.

2.            Hypoxia.  Hopefully, all related to atelectasis.  We will repeat a chest x-ray.

3.            Hypertension has been stable.

4.            History of reflux and gastro esophageal reflux disease, but have been well controlled since the Nissen.  She has actually been off everything.  We are going to put her back on her Protonix while she is in this situation, resume her LexiROM.  Also we are going to put her on Lovenox 30 milligrams b.i.d.  We will replace her potassium.  We have consulted _______ for spine surgery.

NOTE

Preop is for cataract surgery, going to be performed by ___________.  His surgery is scheduled for January 17, 2008.

Ophthalmology Case Study

HISTORY
 Patient is a 53-year-old male who was seen the day prior in my clinic by _________ for some reflux, nausea, and abdominal cramping.  He underwent a KUB, given some Levsin and Nexium.  He said the pain has gotten probably little worse but now he is having recurrent vomiting.  He says he is vomiting about every hour despite the Phenergan.  Has been having fever.  He said he had chills and sweats last night but he did not measure his temperature.  When I saw him today, he walks in gently.  This guy hardly ever comes to clinic except for routine visits for his blood pressure and he is hurting, he is holding his right side walking, getting to lie down.  On examining, he has positive bowel sounds but very hypoactive.  He is tender in his right lower quadrant.  Really no rebound.  Palpating those sides does not hurt and all of his stomach does not hurt and he said he is not sure what he has got.

He had a CBC, his white count of 10.5 with left shift but everything else is normal.  He had a CT scan of his abdomen and pelvis, CT scan reported appendicitis which was consistent with the clinical diagnosis.

CURRENT MEDICATIONS

1.            Zocor 40 milligrams a day.

2.            Nexium 40 milligrams a day.

3.            He is on Toprol-XL 50 milligrams a day .

4.            Norvasc 5 milligrams a day.

PAST MEDICAL HISTORY

He has had hypertension for about 13 years.  He has had hyperlipidemia and he is on the Zocor for about the last 3 to 4 years.  He also has GERD.  Past medical history otherwise is pretty much unremarkable.  ______ and really do not have a knowledge of what is going on. 

FAMILY HISTORY

His father had MI at 52, grandfather at 55.

SOCIAL HISTORY

He has 30 to 40-pack-year history of smoking.  He likes to drink beer.  He works, married, with step child.

OBJECTIVE

VITAL SIGNS:  When I saw, patient's blood pressure was elevated but he was in lot of pain.  His blood pressure was 156/102, pulse 68.

ENT EXAM:  His oropharynx is somewhat dry.  He says he is not been able to keep a whole lot down except for water.  His TMs are clear.

CHEST:  He has bilateral breath sounds and rhonchi.

CARDIAC EXAM:  Revealed a regular rate and rhythm.

ABDOMEN:  He has positive bowel sounds.  He is tender in his right lower quadrant as mentioned above.

RECTAL EXAM:  He had good tone.  His guaiac negative.  He did have some loose stools but he had been taking laxatives, thinking he was constipated but the stool is light brown.  Prostate is not enlarged.

EXTREMITIES:  No edema. 

ASSESSMENT

1.            Acute appendicitis.

2.            Hypertension.

3.            Gastroesophageal reflux disease.

4.            Hyperlipidemia.

5.            Tobacco abuse.

PLAN

To admit to the hospital where I consulted to __________.  He will need emergency surgery, this was explained to the patient, to prevent rupture.  He understands this, I explained risks and benefits.  He said if it ruptures that all the poison will go in my stomach from the appendix, I said that is exactly right, so he said I will get this thing done.  We are setting this up.

Ophthalmology Case Study

HISTORY
Patient is a 58-year-old male who comes in with a long history of diabetic foot ulcer that has not healed.  He has been through wound therapy, but it just stays there, but has been dry.  States about a week ago, it started oozing more and now he has got redness all over the MTP area of his foot, and he has got a secondary ulcer medially that has broken through.  I think this is an extension of his cellulitis.  He has had his great toe removed approximately 1 year ago.  He also had a 2nd metatarsal of his left foot removed in 2005 by Dr. Todd.  He states his ______ and he has been keeping his sugars a lot better and indeed he has, his last hemoglobin A1c was 6.5.

ALLERGIES

He has no known allergies.

CURRENT MEDICATIONS

Humulin 70/30, 20 units in the morning, 20 units in the evening.

He says his sugars run well.  He only checks about once a week secondary to financial restrictions.  He is now out of a job.  He was laid off by Sams when they had to cut back.  He had diabetes for years, but has never really taken care of himself to this point.  He started to have problems and he got series about 3 years ago.  Unfortunately, he has had these complication.

FAMILY HISTORY

At this time, is noncontributory.

SOCIAL HISTORY

He is divorced.  They have 1 adopted child together.  He does not smoke, does not drink.  He does some side computer jobs.

OBJECTIVE

EXTREMITIES:  When I see Mr. Case, he comes in walking on the side of his right foot.  His right MTP and bottom of his foot is red and erythematous.  The ulcer is not much draining out of, but it has got a black eschar above it, but on the medial aspect of the MTP, there is a hole that is draining kind of serosanguineous fluid.

ENT:  His pupils equal, round, reactive to light.  His extraocular movements are intact.  His TMs are clear.

CHEST:  Clear.

CARDIAC:  Regular rate and rhythm.

ABDOMEN:  Soft.  He has lost a lot of weight when he got serious about his sugar.  Over the last 2 years, he has lost close to 70 to 80 pounds.  He lost a lot secondary to uncontrolled diabetes, which has resulted in 2 previous amputations.

ADMISSION DIAGNOSES

1.            Diabetic foot ulcer with cellulitis, suspect osteomyelitis for the secondary tract of an ulcer going to medial aspect of the foot.

2.            Insulin-dependent diabetes.  Last hemoglobin A1c was fine.

3.            Poor overall well being secondary to social restrictions of finances.  He is now living by himself.  He will make his own meals.

4.            Diabetic neuropathy.

PLAN

At this time, we will admit to the hospital.  We are going to start him on IV Zosyn 4.5 g q.8 h.  We will get wound culture.  Put Bactroban ointment on twice a day.  Consult Dr. Todd.  We will continue his glucose previous regimen.

Ophthalmology Case Study

HISTORY
Patient is a 15-year-old female who woke up on July 1 with nausea, vomiting, and diarrhea; all hit her 1 time about 9 o'clock.  She threw throughout the day.  Mom has some Phenergan, but it did not seem to slow her down.  The diarrhea got bad.  She got weaker.  Mom said actually last night, she had encopresis where she had thrown on her bed, this was because she is so weak.  Today, she felt better with the nausea, so she started trying to drink and then the vomiting started over and now she has throw up ______ and still having loose stools and diarrhea.  She does baby-sit 1 kid she kept last week, the mom called her today and said that 1-year-old has diarrhea and has had all weekend, but it is getting better, so she is not sure if she got from there or where else, but she has not done anything else in summer except baby-sit.   She has been in no camps.  She said she felt cold, shivering.  When she stands up, she feels like she is going to pass out, could not fairly get and sit up now.  When I do, she gets lightheaded and feel like she is going to throw up and does not want to move.

PAST MEDICAL HISTORY

She has no known allergies.  She has been hospitalized once for Mycoplasma pneumoniae by myself 6 years ago.  She has no chronic illnesses.  She is up to date on all immunizations.  She has been on Gardasil vaccine and she has gotten the DTaP, so she is up to date on everything current.

SOCIAL HISTORY

She is going to 10th grade and does well in school.

PHYSICAL EXAMINATION

GENERAL:  When I see the patient, she is afebrile.

VITAL SIGNS:  Her blood pressure is 100/50, pulse is read at 100.  Her mouth is dry.  She keep trying to lick her lips.  She wants something to drink, but when she does, she starts throwing up, so she was not given anything at all.

ENT:  Her TMs are clear.

CHEST:  Clear.

CARDIAC:  Tachycardiac rhythm, rate at 100, but is regular.

ABDOMEN:  She has very hyperactive bowel sounds.  Pushing on does not really sore, she says it cramps.   Start up to see if it could be orthostatic change, but she just got lightheaded and felt like she has throws,  we just laid her back down.  Unable to get urine specimen.

ASSESSMENT

1.            Acute gastroenteritis.

2.            Dehydration.

PLAN

At this time, put her in the hospital, started on IV D5 normal saline, ice chips.  We did a CBC and CMP.  Also check stool for C and S and rotavirus for keeping the kid that was sick over the weekend.

Ophthalmology Case Study

HISTORY
Patient is an 18-year-old male who stated on Wednesday, the 2nd, he started having severe sore throat.  On Thursday, he developed temp of 103, hard to keep anything down.  They called our servi____________- called him in, Zithromax, through the phone and he was seen in our clinic on Saturday, the day of 4th.  On Saturday, we performed a rapid strep and mono, both of which were negative.  He was placed on Omnicef, but thinking this was possibly viral or mono that was missed by the mono rapid test.  Patient continued to have fever, chills, severe pain, inability to swallow, and started vomiting.  He was brought to the emergency room on the evening prior to admission.  In the ER, he underwent laboratory testing, which showed that he had severe cryptic tonsillitis or just a lot of exudate.  His electrolytes plus was normal.  His white count was 7.3, H and H was normal.  There was no shift.  Lymphocyte count was only 16%.  His mono test serum was negative.  His UA shows that he has 2+ ketones, 2+ protein.  He was admitted to the hospital for pain control, dehydration, and IV antibiotics for his tonsillitis, and Zofran for his nausea.

PAST MEDICAL HISTORY

He has no known allergies.  He uses albuterol p.r.n. for asthma.  He was hospitalized in 1995 for viral croup by myself.  Otherwise, he has been mainly treated as an outpatient.  He is up-to-date on all his shots.  He does use albuterol on a p.r.n. basis and he has used Azmacort in the past, but as he has gotten older, he has a kind of outgrown most of his bronchospasm problems.

FAMILY HISTORY

His mother is basically healthy, does have some fibromyalgia and other problems.  Father has no chronic medical problems.

SOCIAL HISTORY

He is a rising sophomore at USA.  He lives on campus.  His parents are divorced.  He lives between both of them, but mainly on the campus of the school.  He does smoke some and he has been counseled on this.  He has not smoked since Tuesday; hopefully, we can discontinue this secondary to the exacerbations of asthma that this can cause and this has been explained to him at length.

PHYSICAL EXAMINATION

GENERAL:  Patient is lying in bed, sitting up.  He said it is difficult to drink, but he has had about a 1/2 a cup in hour since he has been here.

HEENT:  Oropharynx reveals exudates bilaterally with cryptic-appearing tonsils.

NECK:  Supple, with very shoddy cervical lymph nodes, nothing prominent.

CARDIAC EXAM:  Regular.

CHEST:  Actually sounds pretty good.  He is not wheezing at this time, but he has had 2 treatments.

EXTREMITIES:  No edema.

ADMISSION DIAGNOSES

1.            Tonsillitis, most likely viral, could be cryptic tonsils with chronic bacterial.

2.            Dehydration secondary to tonsillitis.

3.            Nausea and vomiting secondary to tonsillitis.

PLAN AT THIS TIME

Hydrate with IV fluids.  We will discontinue his Rocephin and put him on Zosyn to cover anaerobes as well.  He has been given Decadron x2.  Continue pain medicines.  He should slowly defervesce.  Other cultures were obtained through the ER.

Ophthalmology Case Study

HISTORY
Patient is a 91-year-old female who states Friday night she started feeling a little short of breath like her heart failure is coming back, it got worse Saturday night and she came to the ER early in the morning on December 30.  She let someone know at Careplace she just was not doing too well and breathing good.  When she presented to the emergency room, she was tachypneic, retracting per ER doctor, and had lot of problems breathing.  She is brought in by the ambulance.  Her O2 sats on 2 L was 92%.  She was given some O2, I guess en route.  They gave her some Lasix.  She had wheezing per ER report, and she diuresed and she feels better.  She is breathing better and said she feels like she can breathe again.  Asked her, has she been increasing her salt or sodium intake, said no, she has been eating too many sweets but nothing else like that.  She has had admissions for this in the past.  She also has chronic renal insufficiency.

PAST MEDICAL HISTORY

She is allergic to SULFA and CODEINE.  She has history of admissions for CHF and renal failure in the past.  Her last admission was in March 2006 from old records that I have obtained.  She has a history of valvular heart disease and chronic renal insufficiency as mentioned.  Her creatinine only runs in the 2.5 to 3 range.  On discharge last time, it was like it was at 3.0, but this was almost 2 years ago.  She is staying at Careplace.  She is actually the great aunt of my partner, Dr. Smith, who cares for her through that facility.  She is a DNR and wants me to make sure that we continue that status.

MEDICATIONS

Her medications at Careplace include: 

1.            Norvasc 10 milligrams a day.

2.            Ziac 5 milligrams a day.

3.            Sinemet 25/100 t.i.d.

4.            She is on Lasix 20 milligrams a day.

5.            Lexapro 20 milligrams a day.

6.            Benicar 20 milligrams a day.

SOCIAL HISTORY

She is not a smoker.  Does not drink.  She has a son who lives in Silverhill.

REVIEW OF SYSTEMS

Patient states before this happened, she had been doing fairly well.  Her tremors got more worse.  Dr. Kasmia, I think, is treating her for movement disorder, maybe early onset Parkinson's.  I do not have that record.

OBJECTIVE

GENERAL:  When I see the patient, she is sitting at about 30 degrees with 2 L oxygen on.  She says she is much more comfortable.  She is a little cold and she has not had her Sinemet last night or today, so she has got a little tremor on the right side that is worse than the left at this time.

ENT EXAM:  Her pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  She does not have any venous jugular distention.

CHEST:  She has crackles bilaterally at about 3rd way up the lung fields and faint expiratory wheezes.

CARDIAC EXAM:  Revealed a regular rate and rhythm with 1/6 to 2/6 systolic murmur at the apex.

ABDOMEN:  Soft.

EXTREMITIES:  She has trace to 1+ edema, about 3rd of the way up.  She has a scar on her right leg that is partially healed.  Her son states she had a basal cell cancer removed recently.

LABORATORY DATA

Her chest x-ray was consistent with CHF, had bilateral lower lobe infiltrates and severe cardiomegaly.  Her urinalysis was nitrite and leukocyte negative.  Specific gravity is 1.025.  Her white count is 18.9, hemoglobin is 9.2, hematocrit 27.0 with a left shift.  INR was normal at 1.1  Her cardiac enzymes were normal.  Her panel-7 showed a glucose of 139 fasting, BUN was 32, creatinine 3.0, BUN/creatinine ratio was 24.  Magnesium is 2.9, brain natriuretic peptide is 1540.  EKG obtained shows a normal sinus rhythm with no acute changes at this time that can be ascertained.  She is comfortable on the 2 L at this time.

ADMISSION DIAGNOSES

1.            Acute congestive heart failure or respiratory compromise.

2.            Chronic renal insufficiency.

3.            Hypertension.

4.            Cardiac asthma.

5.            Anemia, down from her previous discharge.  This could be delusional from her congestive heart failure versus anemia of chronic disease with the renal failure.

6.            History of gastritis.

7.            Advanced age.

PLAN

At this time, we will admit to the hospital with diuresed gently with the BUN and creatinine ratio already being up, trying to keep her comfortable.  O2 might require nebulizers if she starts wheezing.  We will resume her home meds.  She had an echo done 2 years ago.  We might need to bump her Lasix up on a routine basis.  We will see her renal function response.  Repeat a CBC in the morning.  If this is still down, we might have to diurese to give her some blood, so she will be able to compensate for her cardiomegaly and renal failure.

Ophthalmology Case Study

HISTORY
Patient is a 42-year-old male who was seen 2 weeks ago in the emergency room for bronchospasm and saw me a couple of days later, was continued on treatment.  He at the time was a federal policeman, and 2 weeks ago he was chasing a fellow that was running.  He got in a cold air.  He started having shortness of breath and was very tight in his chest, and he presented to the ER with bronchospasm.  At that time, he was treated with nebulizers and given shot of some steroids, and when he presented to my office, he was better, but he still has some mild bronchospasm, so he was put on Symbicort and albuterol routinely.  He was maintained on Zestril and his Nexium.  He also takes Celexa.  He states last night he was doing his regular drive around, he works 6 to 6 the night shift.  He said about 6:30, he started getting short of breath when he was driving.  He pulled over, got 2 sprays of his albuterol.  He said it did not make much difference.  He called in, told me he just felt short of breath, so he went to the house.  He said when he went home, he took a couple more puffs of his inhaler, did not seem to be catching his breath, almost like he had to gasp and he had chest pain along with it as well.  He says he has persistent chest pain, but very atypical, it moves around, always around the center to the left part of his chest.  His arm went numb.  He was getting worse and presented to the emergency room.  In the emergency room, his blood pressure was 143/100.  His respiratory rate was 18 and 20, and he was hyperventilating a little bit, but he was very fearful.  He said he was not, but his wife said he was very anxious and worried.  He was treated in the ER with a nebulizer, given some Lovenox, some Ativan, and some Solu-Medrol.  It seemed like the Ativan helped calm him down, the albuterol helped some but not lot, did not do a whole lot for him.  They did a D-dimer, which was normal.  They did a CT scan of his chest,  with his being a policeman and riding around all the time,  CT of the chest was reported as negative.  He denies any fever or anything else.  He is admitted to the hospital for shortness of breath and chest pain.

ALLERGIES

He has no known allergies.

CURRENT MEDICATIONS

1.            Albuterol MDI.

2.            Nexium 40 milligrams a day.

3.            Lisinopril 20 milligrams a day.

4.            Celexa 40 milligrams a day.

5.            He had Symbicort but it ran out.

He had appendix out about 10 years ago.  He has had hypertension for about a year.  He has some GERD with chronic oral tobacco use, but he had an EGD, which was unremarkable.

FAMILY HISTORY

His mother had bypass about 52, but he said she was a heavy smoker.

SOCIAL HISTORY

He dips about a can of tobacco a day.  He occasionally drinks.  He works as a federal policeman.

REVIEW OF SYSTEMS

He is very concerned why he has not been able to breathe good over the last 2 weeks, and it is almost like he takes 2 or 3 breaths and he has got to gasp for the 3rd one.

PHYSICAL EXAMINATION

GENERAL:  He was asleep when I entered the room.  He woke easily.

ENT EXAM:  He has some gum recession secondary to oral tobacco, but otherwise unremarkable.  His TM's are clear.

CHEST:  He has bilateral breath sounds, which sound clear to me.  I do not hear any wheezes.

CARDIAC EXAM:  Regular rate and rhythm.

ABDOMEN:  He is obese.  He has positive bowel sounds.  He is not tender.

EXTREMITIES:  There is no edema.

RECTAL:  We did not perform rectal examination at this time.

LABORATORY DATA

Includes an EKG which shows a normal sinus rhythm with no acute ST-T wave changes.  Blood gas was pH 7.52, pCO2 was 29, and pO2 was 75.  This was in ER and he was obviously hypoventilating somewhat.  His chest x-ray and CT scan were reported as normal through the ER, and these will be reviewed.  His cardiac enzymes have been negative x2.  D-dimer normal.  His liver enzymes slightly elevated with SGOT of 48, SGPT of 68.  Creatinine slightly elevated at 1.4.  White count was 6.9 with a normal diff. 

ADMISSION DIAGNOSES

1.            Shortness of breath associated with chest pain.  Most likely this is respiratory problem, but with the strong family history and hypertension, I think being a policeman, he needs a workup with GXT and this is scheduled for early January with myself after he gets off the night shifts, so he can get this done, but I am going to consult cardiology.

2.            Hypertension, has been stable throughout the last year in the office.

3.            Gastroesophageal reflux disease, on Nexium, doing well, but he has been burping more the last 2 days.

4.            Obesity.

5.            Situational anxiety, doing well on the Celexa 40 milligrams and still has a lot of social stressors.

At this time we will get a lipid profile in the morning along with the thyroid and sed rate.  We will discuss with cardiology, also with pulmonology.  I think this gentleman is going to need some PFTs just to see where he stands on his breathing, so we can get this corrected, so he can perform his job.  He is getting quite anxious and he is getting to the point where he is concerned about if anything happens, if he has to chase somebody or something else happens.

HISTORY

Patient is a 91-year-old female who states Friday night she started feeling a little short of breath like her heart failure is coming back, it got worse Saturday night and she came to the ER early in the morning on December 30.  She let someone know at Careplace she just was not doing too well and breathing good.  When she presented to the emergency room, she was tachypneic, retracting per ER doctor, and had lot of problems breathing.  She is brought in by the ambulance.  Her O2 sats on 2 L was 92%.  She was given some O2, I guess en route.  They gave her some Lasix.  She had wheezing per ER report, and she diuresed and she feels better.  She is breathing better and said she feels like she can breathe again.  Asked her, has she been increasing her salt or sodium intake, said no, she has been eating too many sweets but nothing else like that.  She has had admissions for this in the past.  She also has chronic renal insufficiency.

PAST MEDICAL HISTORY

She is allergic to SULFA and CODEINE.  She has history of admissions for CHF and renal failure in the past.  Her last admission was in March 2006 from old records that I have obtained.  She has a history of valvular heart disease and chronic renal insufficiency as mentioned.  Her creatinine only runs in the 2.5 to 3 range.  On discharge last time, it was like it was at 3.0, but this was almost 2 years ago.  She is staying at Careplace.  She is actually the great aunt of my partner, Dr. Smith, who cares for her through that facility.  She is a DNR and wants me to make sure that we continue that status.

MEDICATIONS

Her medications at Careplace include: 

1.            Norvasc 10 milligrams a day.

2.            Ziac 5 milligrams a day.

3.            Sinemet 25/100 t.i.d.

4.            She is on Lasix 20 milligrams a day.

5.            Lexapro 20 milligrams a day.

6.            Benicar 20 milligrams a day.

SOCIAL HISTORY

She is not a smoker.  Does not drink.  She has a son who lives in Silverhill.

REVIEW OF SYSTEMS

Patient states before this happened, she had been doing fairly well.  Her tremors got more worse.  Dr. Kasmia, I think, is treating her for movement disorder, maybe early onset Parkinson's.  I do not have that record.

OBJECTIVE

GENERAL:  When I see the patient, she is sitting at about 30 degrees with 2 L oxygen on.  She says she is much more comfortable.  She is a little cold and she has not had her Sinemet last night or today, so she has got a little tremor on the right side that is worse than the left at this time.

ENT EXAM:  Her pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  She does not have any venous jugular distention.

CHEST:  She has crackles bilaterally at about 3rd way up the lung fields and faint expiratory wheezes.

CARDIAC EXAM:  Revealed a regular rate and rhythm with 1/6 to 2/6 systolic murmur at the apex.

ABDOMEN:  Soft.

EXTREMITIES:  She has trace to 1+ edema, about 3rd of the way up.  She has a scar on her right leg that is partially healed.  Her son states she had a basal cell cancer removed recently.

LABORATORY DATA

Her chest x-ray was consistent with CHF, had bilateral lower lobe infiltrates and severe cardiomegaly.  Her urinalysis was nitrite and leukocyte negative.  Specific gravity is 1.025.  Her white count is 18.9, hemoglobin is 9.2, hematocrit 27.0 with a left shift.  INR was normal at 1.1  Her cardiac enzymes were normal.  Her panel-7 showed a glucose of 139 fasting, BUN was 32, creatinine 3.0, BUN/creatinine ratio was 24.  Magnesium is 2.9, brain natriuretic peptide is 1540.  EKG obtained shows a normal sinus rhythm with no acute changes at this time that can be ascertained.  She is comfortable on the 2 L at this time.

ADMISSION DIAGNOSES

1.            Acute congestive heart failure or respiratory compromise.

2.            Chronic renal insufficiency.

3.            Hypertension.

4.            Cardiac asthma.

5.            Anemia, down from her previous discharge.  This could be delusional from her congestive heart failure versus anemia of chronic disease with the renal failure.

6.            History of gastritis.

7.            Advanced age.

PLAN

At this time, we will admit to the hospital with diuresed gently with the BUN and creatinine ratio already being up, trying to keep her comfortable.  O2 might require nebulizers if she starts wheezing.  We will resume her home meds.  She had an echo done 2 years ago.  We might need to bump her Lasix up on a routine basis.  We will see her renal function response.  Repeat a CBC in the morning.  If this is still down, we might have to diurese to give her some blood, so she will be able to compensate for her cardiomegaly and renal failure.

Ophthalmology Case Study

HISTORY
Patient is a 57-year-old male who states Saturday morning he woke up kind of with a click in his neck.  He took an aspirin.  It persisted and he took one of his Voltaren which he had not taken in a while, but he took it about a month ago for his knee, took 3 or 4 days' worth and it worked, so he has just had them around, but he said later in the day, stomach kind of felt full.  Sunday morning, did not feel that good.  He had a bowl of raisin bran.  He states throughout the day the stomach just kept somewhat tighter and full, like he just could not eat anymore and he was bloated.  He has a history of gallstones, which he has not had removed.  He turned down surgery and was just going to watch it.  He is just very fearful of anesthesia, but he said he said this is unlike his gallbladder attacks as he has had 2 or 3 of those.  He went riding around to gas up his car, just thinking that maybe getting up and moving around would help his stomach, kind of move everything.  He went back home because he felt too bad.  His wife went to the drugstore to get some Mylanta.  She called him about 6 o'clock, he had been throwing up blood and he had dark stools that she states smelled real bad and just felt bad, and he just threw up a lot of blood.  He presented to the emergency room with a GI bleed and was evaluated.  In the ER, his abdomen was tender.  He said they gave him some medication; looks like they gave him some fluids, Protonix, and Zofran and he said now he is pretty comfortable.  He said after he threw up a bottle of blood and everything kind of broke loose, he felt better.

PAST MEDICAL HISTORY

He has a history of esophageal ulcers.  He also has a history of squamous cell carcinoma of the lip in 1980.  He has had hypercalcemia in the past, but I think this is associated with alcohol which he used to be a heavy drinker for the last 5 or 6 years, but he has been abstinent for the last 13 months.  He went off to Life Recovery and he has done well.

ALLERGIES

He has no known allergies.

CURRENT MEDICATIONS

Include Zocor 40 milligrams a day.  I gave him some Voltaren 40 tablets on the 28 of May, and he states maybe took them 3 or 4 days; he still has a bunch left.  He had a nuclear stress test in January when he had one of his gallbladder attacks and it was normal.

FAMILY HISTORY

His mother deceased of small cell cancer of the lung and had gallbladder disease.  Dad is alive with dementia.  Sister also had her gallbladder out.

SOCIAL HISTORY

He has been married for 20 years.  He has 2 kids.  He has a 30 pack-year history plus of smoking.  He has been abstinent for 13 months from alcohol.  He owns a candy shop.

OBJECTIVE

GENERAL:  When I see the patient, he is lying in bed sleeping.  He feels much more comfortable.

ENT EXAM:  Basically unremarkable.  He has some ruddy changes in his face which have been chronic.

CHEST:  He has bilateral breath sounds with minimal rhonchi.

CARDIAC:  Revealed a regular rate and rhythm.

ABDOMEN:  He has positive bowel sounds.  He appears slightly distended, but he says he does not feel full at all and he has good bowel sounds now.  Pushing on his upper abdomen he is not hurting, suggested it just felt like a band across there, but nothing like his gallbladder attacks.

RECTAL:  In the ER was positive, so this was not repeated and he had black melenic stools.

White count on admission was 21,700 with a left shift.  H and H were 13.6 and 38.1.  He has O positive blood.  Amylase and lipase were normal.  INR was 1.1.  His electrolytes plus came back down, except for BUN and creatinine.  His hemoglobin has ______ down to 11 and 31.  This is probably a total of about 2 units of blood.

ASSESSMENT

1.            Gastrointestinal bleed, definitely upper gastrointestinal bleed, possibly lower gastrointestinal because it has started turning red in the lower part unless this is rapid transit.

2.            Hyperlipidemia, on Zocor.

3.            Cigarette abuse.

4.            Gallstones.

5.            Past history of heavy ethanol abuse, but it was for about 5 to 6 years, prior to that he was a social drinker and very minimal, but he has been abstinent for 13 months.

PLAN

At this time, I am going to get H and H q.6 h.  Consult ____________-.  EGD is in order.  We will also consider cholecystectomy while he is here.