Ophthalmologist - Ophthalmology Case Study - About Radial keratotomy

HISTORY

Patient is a 59-year-old male who experienced a seizure approximately 8 p.m. after dinner, witnessed by family, it lasted about 5 minutes, and did lose consciousness.  When he awoke, he was aware of everything.  They had called the paramedics.  By the time they got there, he was aware of everything, but he was very tremulous and said he was cold.  He was brought to the ER, evaluated in the ER, was noted to have accelerated hypertension, very tremulous, and elevated heart rate.  He has a past history of heavy alcohol use, according to wife, had actually looked into the Bradford system.  For the last 3 days he had been trying to cut down in hopes of spending time of the holidays with kids so they would not ruin Christmas.  Wife was unaware that just cutting back that much would have caused the seizures because he did have a beer today and a glass of wine and had just made himself a drink, but he had cut back tremendously since Sunday morning when they drove down here from Montgomery where he normally resides.  He has never had anything like this before.  She said he started getting shaky some yesterday, but progressively got some worse today and after dinner led to seizure.

PAST MEDICAL HISTORY

He has no known allergies.  He has hypertension for 26 years.  He has GERD and he takes Celexa and BuSpar, but does not take them all the time.  He has a hard time getting them down.  He admits to drinking Canadian whisky on weekends and after work.  His wife states that he drinks during the week as well and he kind of just puts his head down and says he does not know.

PAST SURGICAL HISTORY

He had surgery for anal fissure years ago.  He had a radial keratatomy years ago.

FAMILY HISTORY

Mom had diabetes and MI at 69.  Dad died of MI at 62.

SOCIAL HISTORY

He works for the state as an auditor.  He has been married for almost 40 years, has 2 children.  He does not smoke.

OBJECTIVE

GENERAL:  When I see patient, he was very tremulous.  He had already gotten some Ativan here in the ER and was getting a banana bag as we spoke and within 30 minutes, his tremulousness was much improved, but he was complaining of being sedated.

HEENT:  His pupils were equal, round, reactive to light.  His extraocular movements were intact.  He smelled of alcohol.  His TMs were clear.  I did not hear any carotid bruit.  He was tachycardic, rate at 108.

CHEST:  Bilateral breath sounds clear.

CARDIAC EXAM:  Revealed a tachycardic rhythm, which is regular.  I did not hear any ectopy and/or murmur.

ABDOMEN:  Soft.  He has some scattered hemangiomas, but I do not see any significant ______.  His liver is felt 1 cm below the costal margin.

EXTREMITIES:  He has no edema.

CT scan of the head is normal.  We are awaiting the laboratory data.

ASSESSMENT

1.            Ethyl alcohol withdrawal.

2.            Ethyl alcohol withdrawal seizure.

3.            Hypertension.

4.            Gastroesophageal reflux disease.

PLAN

He will be admitted to the ICU, will be placed on CIWA protocol, will adapt if needed to other modalities depending on how he does.  The 2 milligrams of Ativan has really done wonders for his unsteadiness.  We will resume his blood pressure medicines by mouth p.r.n. clonidine, also put him on a clonidine patch.  Replace his IV fluids because he has vomited since he has been here.  He is very quiet, withdrawn, somewhat embarrassed.  His wife states this is part of it for him.  I discussed all details with wife and Mr. Huff who is agreeable with the program.