Neurology Case Study

PROVISIONAL DIAGNOSIS

Acute bacterial meningitis.

BRIEF HISTORY

The patient is a 3-1/2-year-old male with a 5-day history of nausea, vomiting, temperature elevation, increasing lethargy.  He was seen and evaluated in the office on the day of admission and brought to the emergency room for lumbar puncture.  This revealed cloudy fluid.  Also, a CBC was consistent with a bacterial process.

PHYSICAL EXAMINATION

Blood pressure 92/64, pulse 100, respirations 24, temperature 100.8.  HEENT revealed marked stiffness of the neck with nuchal rigidity.  Positive Brudzinski, Kernig signs.  Chest was clear.  Heart regular in rhythm.  Abdomen was soft.  Neurologic:  The patient was fairly lethargic and did not respond appropriately to painful stimuli.

LABORATORY DATA

Lumbar puncture revealed normal pressure.  CSF protein 67.  WBC 7040 with 98% polys, 2% lymphs, 210 rbc’s.  Gram stain positive for gram-negative cocci.  CSF glucose 26, serum glucose 96.  CBC revealed WBC of 21.9 with 70 segs, 13 bands, 14 lymphs.  Hemoglobin 11.6, hematocrit 35.1.

PLAN

Patient to be admitted emergently with probable meningitis.

FOOTNOTE

Line 21.  Sign was changed to signs for plural agreement (Brudzinski, Kernig signs).

Line 22.  Neuro was expanded to Neurologic for clarity.

Line 31.  The 2 different laboratory test results (hemoglobin and hematocrit) were separated for clarity.

FE Report

DISCHARGE SUMMARY

ADMISSION DIAGNOSES

1. Preinfarction angina.

2. Secondary arteriosclerotic heart disease.

FINAL DIAGNOSES

1. Preinfarction angina.

2. Secondary arteriosclerotic heart disease.

A 64-year-old white male with a longstanding history of ASHD, intermittent episodes of chest pain for sometime.  Has a known positive treadmill.  Has been on Procardia and Sorbitrate, but stopped Sorbitrate because of headaches.  During the past
24 hours, he has noticed some increase in his pain and has had 5 separate episodes lasting 10 to 15 minutes each, which usually respond to nitroglycerin.  Because of this problem and the increasing severity of the pain, he was admitted to the hospital with a blood pressure of 140/70, pulse 60 and regular, respirations were 14.  Lungs were clear.  Heart regular sinus rhythm, sounds were of pretty good quality.

The patient was seen in the office, admitted to the hospital where an admission panel revealed only a BUN of 23.8, the CPK isoenzymes were normal.  Chest x-ray was essentially unremarkable.  Initial ECG was consistent with his disease, and following discussion with a cardiologist, the patient was transferred with the diagnosis of preinfarction angina for studies and possible corrective procedure.

FE Report

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INDICATIONS

This 49-year-old female presents complaining of elevated temperature for 3 days accompanied by vomiting over that same time frame.  She was evaluated here in the emergency department within the preceding few days and presents at this time with a temperature of a 105.3, pulse of 120, respiratory rate 26, and blood pressure 140/76.

Physical assessment revealed there was no nuchal rigidity. Pharynx was clear.  Heart rate regular.  Abdomen was soft.  Rectal exam deleted.  Lower extremities free of any significant pretibial edema.  There was bilateral negative Homans.

PLAN WHILE IN THE EMERGENCY DEPARTMENT

Multiple diagnostic studies were performed including CBC.  She had a white blood count of 9900, 74 segs, 9 bands, hemoglobin 11.3, glucose 121, sodium 133, potassium 3.2.

Catheter urinalysis showed 3+ bacteria, 40 to 50 white blood cells, 60 to 70 red blood cells, specific gravity of 1.025.

IMPRESSION

Sepsis, rule out pyelonephritis.

FE Report

CHART NOTE

The patient is a 68-year-old female looking much older than her stated age, who noted a mass in her left breast.  The radiologist felt that this was clear-cut evidence that there was a carcinoma of the left breast.  Blood pressure was 180/90.  In the left breast and the midportion of the breast, roughly behind the nipple, a mass estimated to be 2 to 2.5 cm in size is palpable.  This was quite firm, no axillary nodes could be palpated.  The alternatives of a lumpectomy and radiation have been discussed with the patient, and she prefers not to consider them.

Endocrinology Case Study

EMERGENCY ROOM REPORT

This 67-year-old female was evaluated by me in the emergency department at approximately 0630 hours for complaints of repeated episodes of vomiting, numbering at least 5 during the preceding 8 or so hours.  She stated that she is a known diabetic and has taken fingerstick readings of 423 and 241 at home.  She is on multiple medications including regular insulin 10 units in the a.m., along with Ultralente 16 units at h.s., along with Trental, Pamelor, and niacin.  She is a known diabetic for 54 years.  She also admits to some chest pain, somewhat burning in nature, without radiation into her face, neck, or arms.  There is no history of diarrhea.  She has a previous history of coronary artery bypass surgery some 4 years earlier.

PHYSICAL ASSESSMENT

Physical assessment reveals her temperature to be 98.2, pulse 60, respirations 20, and a blood pressure of 102/50.  Initially her color was pale.  Her mucous membranes did appear dry.  Heart rate was regular without murmurs.  There was a well-healed cicatrix to the anterior midsternal region.  Lungs were clear to auscultation.  The abdomen was soft with generalized tenderness.  No unusual pulsating masses.  Lower extremities were free of any pretibial edema.

IMPRESSION

1. Diabetes mellitus, out of control.

2. Dehydration.

3. Electrolyte imbalance.

PLAN

While in the emergency department, multiple diagnostic studies were performed, including CBC, glucose, BUN, potassium, sodium, UA, Panel A, ABG, PT, PTT, electrocardiogram, CPK-MB via electrophoresis.  Her serum glucose was noted to be 511, serum sodium of 129, and a BUN of approximately 30.

During her ER stay she was given normal saline with some subjective improvement.  She was also given Compazine 10 mg IM for repeated vomiting.  Her condition at the time of admission was slightly improved.

FOOTNOTE

Line 9 (Page 1).  In duration was deleted.  (Duration indicates time span.  Five episodes of vomiting is the amount, not the duration.)

Line 11 (Page 1).  Alternative:  Finger stick.

Line 36-40 (Page 1).  The abbreviations used were expanded for clarity.

Line 42 (Page 1).  Plan was deleted since it had already been dictated in

Line 43 (Page 1).  Alternative:  I.M.

Endocrinology Case Study

CHART NOTE

A 34-year-old lady who comes to clinic today with longstanding history of hypothyroidism, for which she has taken Cytomel in the past.  Comes in today for a refill of medication and further evaluation.

Examination shows her to be in no acute distress.  Blood pressure 120/88.  HEENT normal.  Chest is clear.  Cardiac examination reveals regular rate and rhythm without murmur.

ASSESSMENT

A 34-year-old lady with longstanding hypothyroidism.  I would prefer to switch her to Synthroid 0.1 mg as I think the packaging is more uniform in this product.  Then test thyroid-stimulating hormone in 1 month.

FOOTNOTE

Line 7.  The article A was added to avoid beginning the sentence with a numeral.

Line 13.  The blood pressure value 120 by 88 is written 120/88.

Line 18.  A zero was inserted before the decimal point for clarity.

Lines 19, 20.  TSH is expanded in the assessment for clarity.

Endocrinology Case Study

CHART NOTE

A 26-year-old referred for Graves disease.  Patient first found to be hyperthyroid shortly after she became pregnant, was placed on PTU 350 mg taken in divided doses until 1 week prior to delivery.  She has all the classical symptoms of hyperthyroidism, including tremors, soft frequent stool, being hot, insomnia, weakness in her legs, and exophthalmos.

On physical examination, extraocular movements were fairly full except that she could not converge.  Examination of her thyroid revealed the gland to be at least 2 times the normal size with classical, rather mushy, soft feeling of hyperthyroidism.  No nodules were noted.  Examination of her skin revealed normal amounts of forearm hair but extension of hair on the backs of her hands.  She was also beginning to get hair formed on the upper lip at the corners of her mouth.  There is no periareolar hair; however, she has a well-developed male escutcheon.

I talked with the patient about this, and when she has been euthyroid for a bit, we will consider measuring her androgen level.  Patient was asked to discontinue PTU and obtain a T4 and T3.  Appointment was made with Nuclear Medicine for her to have an uptake scan and therapy next week.  I decided to investigate the androgen problem at a later date when we will not have the effect of thyroxine on liver metabolism.

FOOTNOTE

Line 7.  The article A was inserted before 26 to avoid beginning the sentence with a numeral.

Line 27.  Alternative:  Nuclear medicine.

Endocrinology Case Study

HISTORY

This is a 68-year-old woman who was seen probably about 3 years ago with a large colloid goiter.  She was going to have surgery then but declined and came back in more recently because of increasing size of the goiter and the pressure symptoms in her neck and throat.  Studies previously done showed this to be a nontoxic goiter.  She was essentially euthyroid.  Because of its increasing size, the possibility of malignancy had to be considered.

Physical examination was not remarkable except the patient being somewhat overweight and the large goiter which was visible and the right side being larger than the left.  The patient, because of religious customs, would not allow a pelvic or rectal examination.

Following surgery, the patient had no problem speaking.  She is swallowing and eating solid food.  Throat is sore.  She did develop a temperature up to 101 and had some rhonchi in both bases on auscultation.  Chest x-ray shows discoid atelectasis with probable pneumonitis.  Her white count was elevated at a little over 12,000 with a left shift.  Temperature this morning is 100 degrees.  The wound is clean and dry.  The drain has been removed, and one-half of the staples are removed.  She will be continued on tetracycline 500 mg q.i.d., and she is instructed to take her Lanoxin daily and her Dyazide as well.  We are giving her Synthroid, and she is to take that every day.  I have stressed the importance to her son of taking the Synthroid, as she should have no thyroid function.  Her calcium was 8.6.

FOOTNOTE

Line 11 (Page 1).  The dictator said same for the Final Diagnosis, indicating it is the same as the Admitting Diagnosis.  For clarity the Final Diagnosis should be repeated in full.

Line 37 (Page 1).  Degrees was not dictated with the temperature of 101 but it is acceptable to add it to be consistent with the later expression.

Endocrinology Case Study

HISTORY AND PHYSICAL EXAMINATION

This 36-year-old man was doing well until 3 years ago, when he developed progressively severe fatigue.  At that time he had been in a stressful job situation.  However, these symptoms have persisted and gotten worse, although the stress has improved.  There is no relation to meals or time of day, although he is somewhat more tired in the afternoons.  He sleeps 7 to 8 hours during the week and 12 hours on weekends.  Chemistry-2, CBC, Epstein-Barr studies, and thyroid function tests have been normal.  Was tried on Thyrolar one-half grain because of low normal T4, but there was no benefit.  Has received Parnate, Nardil, and other antidepressants, including vitamin B12 injections, without any benefit.  He has a 3-year history of constant burning in the eyes.  An ophthalmologist did not find anything wrong.

REVIEW OF SYSTEMS

Has periodic dizziness particularly when standing up rapidly, occasional tinnitus, frequent constipation and occasional diarrhea, nocturia x2 or 3, cold extremities, and dry skin of relatively recent onset.  Has some anxiety and insomnia and is depressed, apparently in relation to his condition.

FAMILY HISTORY

Father has heart disease.  Brother has retinitis pigmentosa.

HABITS

Drinks coffee.  Diet is balanced and low in sugar.

PHYSICAL EXAMINATION

VITAL SIGNS:  Height 6 feet 1 inch, weight 190 pounds.  Blood pressure 130/72, pulse is 68.

HEENT:  HEENT is normal.

NECK:  Neck is normal.

HEART:  Heart is normal.

LUNGS:  Lungs are normal.

ABDOMEN:  Abdomen is normal.

PULSES:  Pulses are normal.

EXTREMITIES:  Extremities are normal.

GROSS NEUROLOGIC:  Gross neurologic examination is normal.

SKIN:  Skin is normal.

RECTAL:  Rectal examination not done.

ASSESSMENT

1. Chronic fatigue.

2. Burning eyes.

3. Depression.

4. Signs of possible hypothyroidism.

5. Constipation and diarrhea.

PLAN

We will check basal temperatures and begin thyroid prescription if low.  Gave therapeutic trial of 6-cc vitamin C, 4-cc calcium/magnesium, 1 cc of B6, B12, B5, and B complex IV.  Will repeat if helpful.  Other recommendations as noted and return in 4 weeks.

FOOTNOTE

Line 13 (Page 1).  Chem was expanded to Chemistry.  Exam was expanded to Examination.

Line 35 (Page 1).  Exam was expanded to Physical Examination.  Line 36 (Page 1).  Height and weight was added for clarity.

Lines 36-47 (Page 1).  The subheadings were added in Physical Examination to follow proper format.

Line 9 (Page 2).  Alternative:  I.V. (intravenous).  The slang term cal/mag was expanded to calcium/magnesium for clarity.