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.