Ophthalmology Case Study

HISTORY
Patient is a 37-year-old male who was driving back from Mobile after visiting his daughter this afternoon.  He said he was in Loxley.  He started having some chest discomfort, which he describes is like explosion or a balloon bursting in his chest.  He had pain down his left arm and he had a brief syncopal or near-syncopal episode where he drove off into a ditch and over a couple of culverts and then he woke up in front of a speed sign, then he drove on home.  He was brought to the emergency room by his wife at approximately 9 p.m.  He states he has been having some pain down his left arm and his chest since Friday.  He thought he was going to get better over the weekend when he took off, but it really had not got much better.  He denies any other symptoms.  He did state when he was in the truck he was sweating a little bit.  In talking with his brother who is here with him as well as his employer, they always tease him about passing out in pain.  He says he has always had that problem, but he also when he gets his blood drawn he would pass out and they tell him it is the nerve that makes him pass out, and he said he had done that before, but he is not sure if that was the cause tonight or not.

PAST MEDICAL HISTORY

He has no known allergies.  He is on Vytorin 10/80 milligrams from Dr. Studdard, his regular doctor over at Spring Hill.  He has had cholesterol problems for the last 7 to 8 years.  It runs in his family, pretty bad according to him and his brother.  Otherwise, he has had no surgeries.  No other procedures.

FAMILY HISTORY

His mother had heart disease at 59.  She had some stents.  She has had cholesterol problems most her life.  His biological father, he did not know much about, but he does know that he has diabetes.

SOCIAL HISTORY

He is married.  He has 4 children.  He does not smoke.  He does not drink.  He works for Easy Hall, here south of Fairhope.

REVIEW OF SYSTEMS

He denies any GI problems.  He has had some neck discomfort over the last few days and maybe longer than that.  He is not sure how long but he says it has been a little stiff, and on that exam, he does have a positive Spurling test to the left, but he says not all the time it is coming he gets irritated.

LABORATORY DATA

Reviewed.  His CBC was all within normal limits.  D-dimer was normal.  Cardiac enzymes initially were negative, drawn at 11 p.m.  This will be repeated at 6 a.m.  He has a drug screen that was negative, multi ______ all within normal limits.  EKG showed a normal sinus rhythm.  There were no acute ST-T wave changes noted at all.  Chest x-ray was normal.  Telemetry strip in the ER was normal.

ADMISSION DIAGNOSES

1.            Chest pain, rule out myocardial infarction.  Chest x-ray and D-dimer normal.  Sounds possibly    cardiac.  Could be gastrointestinal in nature.

2.            Severe hyperlipidemia.  He was on a high dose of Lipitor at one time and Dr. Studdard switched him to Vytorin a couple of years back.

3.            Syncopal or near-syncopal episode.  Has had vagal events in the past.  At this time, we will put him in the hospital, keep him on telemetry monitoring, repeat a further set of enzymes, repeat his electrocardiogram, get a lipid profile in the morning.  If his electrocardiogram and enzymes are normal, we will get a cardiology consult, most likely do a stress test tomorrow for further determination.  His neck and arm can be worked up as an outpatient if his stress test is normal.  We will resume his Vytorin and aspirin was given in the emergency room.