NEW Medical Case Studies - Case Study

PROBLEM LIST

1.            Type 2 diabetes x4 years has not been checking glucoses until recen

2.            Hyperlipidemia x4 plus years.

3.            Hypertension.

4.            Bipolar disorder.

5.            Umbilical hernia symptomatic, this is what brought him to the emergency room.

6.            Right facial nerve palsy, ___________ has consulted.

7.            Recent URI.

8.            Overweight. 

BRIEF HISTORY

The patient is a 51-year-old male who states he went to urgent care because he started having some abdominal discomfort.  He has an umbilical for about 10 years but over the last 2 weeks it has gotten increasingly sore and more discomfort.  He started having some pain radiating to the right and when he pushed it back in he would have pain below it.  He has not strained or lift anything to cause any recent worsening.  He also states that he had a cold last week, was not feeling good so he had started what he thought was a sinus infection so he started checking his sugar because he is a diabetic and had not been checking and he said he got a 444 and it kind of scared him.  He was seen in Thomas emergency room diagnosed with symptomatic right umbilical hernia and admitted to ______ service.  Also noticed that he had a 7th nerve palsy on the right, ____ consulted and I have been consulted for other care.  He states he is very compliant with his medication.  Has not been compliant as mentioned above checking glucoses, but now he is doing that.  

ALLERGIES

He has no known allergies.

Include: 

1.            Diovan 160 daily.

2.            Metformin 1000 milligrams daily.

3.            Vytorin 10/40 daily.

4.            Cymbalta 30 milligrams b.i.d.

5.            Lamictal 200 milligrams daily and these 2 are administered by Dr. Pollard, Alabama Psychiatric Services. 

OTHER PAST MEDICAL HISTORY

He has been hospitalized in the past for several accidents including car accidents and motorcycle accidents, but  has had no surgeries.  He was hospitalized at South Baldwin about 2 or 3 years ago for chest pain.  He had he said the million-dollar workup.  He underwent stress test and heart cath, everything was clean, they told him he had clean coronary arteries.  

FAMILY HISTORY

At this time noncontributory.

SOCIAL HISTORY

He does not smoke.  He does not drink.  He has been married for 14 years, this is his 2nd wife.  He has 2 children by his current marriage age 12 and 9.  He owns his business in Gulf Shores.  

PHYSICAL EXAMINATION

GENERAL:  When I patient he is a middle-age male in no acute distress who has an obvious 7th nerve palsy.  ENT:  His right-side of his face is weaker.  He has right facial droop, unable to totally close his eye.  The left-side is fine.  His TMs are clear.  I do not hear any carotid bruits.  CHEST:  He has bilateral breath sounds, clear to auscultation.  CARDIAC:  Revealed a regular rate and rhythm without murmur, gallop or rub.  ABDOMINAL:  He has some truncal obesity.  He has positive bowel sounds, has a protuberant umbilical hernia.  When you push it back in it causes pain down below and to the right.  He said they got a UA in the ER but I do not see where this was ordered, I do not see one.  I asked if the urgent care doctor did one down in Orange Beach, he said no.  NEURO:  Besides the 7th nerve palsy is normal.  He still has normal sensation in his feet.

LABORATORY DATA

His amylase 85, lipase 101, white count was 9.8 with a normal diff.  Electrolyte plus, his random sugar was 397, sodium 135.  His lipid profile showed a cholesterol of 201, LDL of 108, triglycerides at 259.  His sugars have been 192 and 363 but the 363 was after receiving some IV Decadron and he has not received his metformin today, her normally takes in the morning so he has not taken it now over 6 hours.  

RECOMMENDATIONS

I am going to resume his previous cholesterol and blood pressure medicine.  I am going to change his metformin to Glucovance 5/500 b.i.d.  Change his Accu-Cheks to q.a.c and bedtime, get a hemoglobin A1C along with PSA and a urinalysis.  If greater than 5 white cells get a urine culture.  We will discuss with Dr. Nechtman and Dr. Wilson about the umbilical surgery with him having this Bell's palsy and being on steroids and possible poor glucose control.  If his A1C is real high this can be put off, it might be advantageous for healing purposes.  This was discussed with patient and he understands and he is very compliant and very open to the suggestions.