Ophthalmology Case Study

HISTORY
Patient is a 58-year-old male who has been recently diagnosed with prostate cancer.  He states that it was in one part of the prostate.  He tells me that the CT scan and bone scan were all okay but they are studying up for a suprapubic radical prostatectomy with partial lymph nodes.  I assume they are going to just get lymph nodes while in there, but he told Ms. Tolbert that his CT scan looked like there was not at the time so he is not sure, but he said that he always leave the option open.  He states that otherwise he feels fine.  He is still driving a truck for Mr. Radcliffe, which he has been doing for years.  He said his sugar has been pretty good controlled.  He kind of keeps a better eye on it and he has been watching things better.  He has not had an eye exam recently and he said that is his fault.  He is going to get an eye doctor in Mobile, where he moved to.

PAST MEDICAL HISTORY

He has no known drug allergies.  

He is currently on: 

1.            Glucovance 5/500.  He takes 2 tablets in the morning, 1 in the evening.

2.            He is on Zestoretic 20/12.5 daily.

3.            He is on Cardura 2 milligrams a day that helps with his BPH.

4.            He is on Procardia XL 60 milligrams a day.

He has had hypertension for 16 years.  He has been a diabetic for 10 years.  At 1st, poorly controlled but over last 2 years has been excellent.  His fasting hemoglobin A1c in March was 6.7.  Today, it is 5.8, so this is excellent.

FAMILY HISTORY

His father still alive.  Only thing he knows he had his gallbladder.  His mom died of some type of stomach or internal cancer, he is not sure of what kind.  He has 5 sisters to the best of his knowledge are pretty healthy.  He had 1 brother who died from multiple strokes, but was a heavy drinker and smoker, he is not sure if that is what caused this or not.

SOCIAL HISTORY

He is separated from his current wife.  He has 2 children.  He lives in Mobile by himself.  He does not smoke and never has.  He used to drink beer, pretty frequently back up until about 1993 and then, he basically stopped.  He might have 1 beer every now and again now.  Since he has got the blood pressure and diabetes, he has really tried taking care of himself.

PHYSICAL EXAMINATION

GENERAL:  When I see the patient, this is a middle to late age white male, in no acute distress.

VITAL SIGNS:  His blood pressure is 140/80.  His pulse is 76 and regular.  His weight is 195, which is stable for this gentleman.

ENT EXAM:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  I cannot detect a carotid bruit.

CHEST:  He has bilateral breath sounds, perfectly clear to auscultation.

CARDIAC EXAM:  A regular rate and rhythm with a 1/6 to 2/6 systolic murmur, which is chronic.

ABDOMEN:  Benign.  He has no masses.  I do not find any organomegaly.

EXTREMITIES:  He has no edema.  No ulcers on his feet.  He still has got good sensation in his feet and he said he feels everything fine.

RECTAL EXAM:  Did not need a rectal exam at this time as he has already been diagnosed with prostate cancer and they got a diagnosis going.

LABORATORY DATA

Did do an EKG.  His EKG shows a normal sinus rhythm.  He has LVH by voltage with reciprocal changes, borderline left axis deviation.  He has inferior Q waves noted in III and aVF.  These were similar to his EKG changes in 1998.  He has had echocardiogram in 2002, which showed no wall motion abnormalities, just that he had a left ventricular hypertrophy, minimal to moderate, which is probably from his blood pressure and treat that well first.  Chest x-ray was perfectly clear.  There were no masses or infiltrates, reviewed with medical staff.  Laboratory data is pending.

ASSESSMENT

1.            Prostate cancer, scheduled for prostate surgery.  Patient is cleared from medical standpoint.  He understands the risks and benefits to the best of his knowledge and he wants to get this surgery ______ saving down his life before his cancer spreads.

2.            Type 2 diabetes mellitus, good control over the last few years.

3.            Hypertension, well controlled.

4.            Past history of ethyl alcohol, minimal now to none over the last 14 to 15 years.

PLAN

Await on laboratory data.  If the laboratory data is all within normal limits, then he is cleared to go to surgery.