Ophthalmology Case Study

HISTORY
Patient is a 42-year-old male who was seen 2 weeks ago in the emergency room for bronchospasm and saw me a couple of days later, was continued on treatment.  He at the time was a federal policeman, and 2 weeks ago he was chasing a fellow that was running.  He got in a cold air.  He started having shortness of breath and was very tight in his chest, and he presented to the ER with bronchospasm.  At that time, he was treated with nebulizers and given shot of some steroids, and when he presented to my office, he was better, but he still has some mild bronchospasm, so he was put on Symbicort and albuterol routinely.  He was maintained on Zestril and his Nexium.  He also takes Celexa.  He states last night he was doing his regular drive around, he works 6 to 6 the night shift.  He said about 6:30, he started getting short of breath when he was driving.  He pulled over, got 2 sprays of his albuterol.  He said it did not make much difference.  He called in, told me he just felt short of breath, so he went to the house.  He said when he went home, he took a couple more puffs of his inhaler, did not seem to be catching his breath, almost like he had to gasp and he had chest pain along with it as well.  He says he has persistent chest pain, but very atypical, it moves around, always around the center to the left part of his chest.  His arm went numb.  He was getting worse and presented to the emergency room.  In the emergency room, his blood pressure was 143/100.  His respiratory rate was 18 and 20, and he was hyperventilating a little bit, but he was very fearful.  He said he was not, but his wife said he was very anxious and worried.  He was treated in the ER with a nebulizer, given some Lovenox, some Ativan, and some Solu-Medrol.  It seemed like the Ativan helped calm him down, the albuterol helped some but not lot, did not do a whole lot for him.  They did a D-dimer, which was normal.  They did a CT scan of his chest,  with his being a policeman and riding around all the time,  CT of the chest was reported as negative.  He denies any fever or anything else.  He is admitted to the hospital for shortness of breath and chest pain.

ALLERGIES

He has no known allergies.

CURRENT MEDICATIONS

1.            Albuterol MDI.

2.            Nexium 40 milligrams a day.

3.            Lisinopril 20 milligrams a day.

4.            Celexa 40 milligrams a day.

5.            He had Symbicort but it ran out.

He had appendix out about 10 years ago.  He has had hypertension for about a year.  He has some GERD with chronic oral tobacco use, but he had an EGD, which was unremarkable.

FAMILY HISTORY

His mother had bypass about 52, but he said she was a heavy smoker.

SOCIAL HISTORY

He dips about a can of tobacco a day.  He occasionally drinks.  He works as a federal policeman.

REVIEW OF SYSTEMS

He is very concerned why he has not been able to breathe good over the last 2 weeks, and it is almost like he takes 2 or 3 breaths and he has got to gasp for the 3rd one.

PHYSICAL EXAMINATION

GENERAL:  He was asleep when I entered the room.  He woke easily.

ENT EXAM:  He has some gum recession secondary to oral tobacco, but otherwise unremarkable.  His TM's are clear.

CHEST:  He has bilateral breath sounds, which sound clear to me.  I do not hear any wheezes.

CARDIAC EXAM:  Regular rate and rhythm.

ABDOMEN:  He is obese.  He has positive bowel sounds.  He is not tender.

EXTREMITIES:  There is no edema.

RECTAL:  We did not perform rectal examination at this time.

LABORATORY DATA

Includes an EKG which shows a normal sinus rhythm with no acute ST-T wave changes.  Blood gas was pH 7.52, pCO2 was 29, and pO2 was 75.  This was in ER and he was obviously hypoventilating somewhat.  His chest x-ray and CT scan were reported as normal through the ER, and these will be reviewed.  His cardiac enzymes have been negative x2.  D-dimer normal.  His liver enzymes slightly elevated with SGOT of 48, SGPT of 68.  Creatinine slightly elevated at 1.4.  White count was 6.9 with a normal diff. 

ADMISSION DIAGNOSES

1.            Shortness of breath associated with chest pain.  Most likely this is respiratory problem, but with the strong family history and hypertension, I think being a policeman, he needs a workup with GXT and this is scheduled for early January with myself after he gets off the night shifts, so he can get this done, but I am going to consult cardiology.

2.            Hypertension, has been stable throughout the last year in the office.

3.            Gastroesophageal reflux disease, on Nexium, doing well, but he has been burping more the last 2 days.

4.            Obesity.

5.            Situational anxiety, doing well on the Celexa 40 milligrams and still has a lot of social stressors.

At this time we will get a lipid profile in the morning along with the thyroid and sed rate.  We will discuss with cardiology, also with pulmonology.  I think this gentleman is going to need some PFTs just to see where he stands on his breathing, so we can get this corrected, so he can perform his job.  He is getting quite anxious and he is getting to the point where he is concerned about if anything happens, if he has to chase somebody or something else happens.

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.