She is Allergic to DEMEROL - CHEST - CARDIAC - ABDOMEN - EXTREMITIES

HISTORY

The patient is an 84-year-old female who called 911 last night around 11 o'clock.  She said during the day she had just felt kind of weak.  She said to one of her neighbors on the phone that said she was not speaking as clearly, but she noticed both hands were weak and she had dropped some things, but during this whole episode and timeframe, which was about 7 hours, she said about 4 or 5 o'clock in the afternoon, she managed to wash dishes and feed herself.  She did not take any of her night medicines because she was kind of concerned and she started thinking she might be having a stroke, so she just stayed home until she went to sleep, then she woke up, because she never could go to bed worrying about something was wrong with her, so she called 911.  They came and evaluated her and brought her to the emergency room with all her medications.  She states she did not take her nighttime medicine of Betapace or the Klonopin or Mirapex for restless legs because she did not want to interfere with anything. 

ALLERGIES

She is allergic to DEMEROL.

CURRENT MEDICATIONS

Include: 

1.            Norvasc 5 milligrams a day.

2.            Hyzaar 100/25 milligrams a day.

3.            Betapace 80 milligrams b.i.d.

4.            Mirapex 0.25 at night.

5.            She has been taking Relafen 500 b.i.d. intermittently for arthritis.

6.            She has Soma tabs as needed for muscle pain.

7.            She takes Klonopin 1 milligram at night for sleep.

8.            She takes GoLYTELY on a p.r.n. basis for constipation.

PAST MEDICAL HISTORY

She has a history of atrial fibrillation for the past number of years.  She is intolerant to the Coumadin as she has had falls.  She is now walking with a walker and is not the most stable person.  She lives at home with a sitter coming in 3 to 4 times a week and friends taking over because she is a widow, with no immediate family close by except in Mobile.  She had a right hip fracture 10 years ago and after that had a DVT.  She had bladder surgery about 2 years ago for bladder tack.  She has had hypertension for a number of years and restless legs syndrome and insomnia for a number of years.

FAMILY HISTORY

Noncontributory.

SOCIAL HISTORY

She is widowed.  She has a son who is estranged, she has not seen for years.  She has 2 granddaughters in Mobile to check on her.  They have been asking to come to Mobile for years, but she is always refusing because they have young kids and she does not want to interfere with their life, so she has lived at home.

REVIEW OF SYSTEMS

Patient was on Coumadin a while for the atrial fib, sustained a fall.  Balance got progressively worse, and it was felt that she is not a candidate for Coumadin any longer secondary to her risk to falls, and she uses a walker at this time.

OBJECTIVE

VITAL SIGNS:  In the ER, her blood pressure 187/106, her pulse is 98, O2 sats are 96.

GENERAL:  Her speech is clear and I can understand every word she says, but it sounds almost lethargic, but she said she has not slept all night.  I see her at 7:30 in the morning, and she said she has been in the ER since 1 o'clock and they did not get her up to a room until 5:30, and she told the nurses that she was just tired, and that was possibly it.

HEENT:  Her pupils are equal, round, and reactive to light.  Her extraocular movements are intact.  Her oropharynx, she has an equal smile.  Her speech is understandable.  She can close her eyes tight.

CHEST:  She has bilateral breath sounds, clear.

CARDIAC:  Her cardiac exam revealed an irregularly irregular rhythm, but rate controlled in the 80s.

ABDOMEN:  Her abdomen is soft.

EXTREMITIES:  She has bilateral nonpitting edema, which is chronic.  Her left leg is worse than the right.  This is the one that she had sustained the DVT, and then she also had trauma to it a few years back with a golf cart incident.

NEURO EXAMINATION:  She is alert and oriented x4.  She knows her address, where she lives and home or social situation, but she is very obstinate in that she is going to go back home if possible.  She has a negative ulnar drift.  She has equal grip strength.  Both legs move okay, the right leg moves a little stiffer secondary to hip replacement.  She has got equal strength, albeit weak, but this is a chronic finding in this lady.

GU AND RECTAL:  Deferred at this time.

IMAGING

EKG showed atrial fibrillation.  CT scan of the head was read with some old cerebellar ischemia, but nothing new on this time.

LABORATORY DATA

Laboratory data reviewed.

ADMISSION DIAGNOSES

1.            Cerebrovascular accident versus transient ischemic attack.  At this time, she seems to be back to her baseline, although she was lying in bed and I did not get her up and walk her, but she seemed to be back to baseline.  She says that she can get up and go to the restroom.

2.            Chronic atrial fibrillation.  Patient is not on Coumadin any longer.  She is at risk for falls and has fallen, and she walks with a walker.

3.            Hypertension, elevated in the emergency room, but now has come down.

4.            Restless legs syndrome.

5.            Status post right hip fracture.

6.            Advanced age.

7.            Hypokalemia.

8.            Hypomagnesemia.

PLAN

At this time, I am going to consult neurology.  __________ has seen her husband.  That is one person she knows.  We will call and see if he is in town.  We will get echo and carotids.  We will also start on a full aspirin a day since she has been on a baby aspirin.  We will get speech and PT evaluation, monitor her blood pressure, replace her magnesium and potassium

Violent Chills, Fever, Altered Mental Status Case Studies

HISTORY

Patient is a 77-year-old female who states for the last 3 days, she has had a history of frequency, dysuria and taken AZO over the counter.  Today she started having violent chills, fever, altered mental status and her husband just brought her to the emergency room because he was concerned and she was talking out of her head.  She is kind of confused which is very unlike Mrs. Sweatt.  She is normally very sharp.  She is a patient of my partner, Dr. Brummett.  She recalls my name.  She knows her history, but just says she has just been so sick she cannot think, but she got some Tylenol here and she is starting to break her fever and has some chills. 

PAST MEDICAL HISTORY

She has had a bladder tack in the past by Dr. Hunt.  Otherwise she says she has had no surgeries besides Dr. Meichner has taken care of her for diverticulosis along with reflux and she has had to have dilatations and some of this obtained from her and old records. 

ALLERGIES

She has no known allergies.

MEDICATIONS

1.            She is on Prevacid 1 a day.

2.            A blood pressure pill.  She says a low-dose water pill, but she is not sure of the name of it.  She has been on it for the last 3 years.

FAMILY HISTORY

Noncontributory.

SOCIAL HISTORY

She does not smoke.  She does not drink.  She had 2 children, one died secondary to MI.  She has been married almost 57 years and she is normally very healthy.  She has been admitted to the hospital once before she said for a kidney infection, but she said that was a few years back.

OBJECTIVE

GENERAL:  When I see patient, she is an elderly female who is shaking and said her stomach is hurting and I think it is her side as well.  She said it just feels like she is still having burning as well.  She has hardly been able to drink or eat much at all over the last 24 hours.

ENT:  Oropharynx is very dry.  Her TMs are clear. 

NECK:  I cannot detect any carotid bruits.

CHEST:  She has bilateral breath sounds, decreased in the bases, but she cannot take deep breaths because it hurts her side.

CARDIAC:  Regular rate and rhythm with the rate right at the 80s to 90s.

ABDOMEN:  She has positive bowel sounds, but is tender in both quadrants in the CVA regions but also in the abdomen.

EXTREMITIES:  She has nonpitting edema. 

PELVIC:  Did not do a pelvic exam at this time secondary to distress.

DATA

Urinalysis was very cloudy.  She had positive nitrite, 3+ leukocyte.  She had greater than 100 white cells per high-power field, 11 to 20 red cells.  Other laboratory data:  Her brain natriuretic peptide was 304.  Blood gas showed a pH of 7.5, pCO2 of 30, pO2 of 71.  EKG showed a normal sinus rhythm.  White count was 27,000 with a left shift.  She has 88 segs, 6 bands.  H and H normal at 11.7 and 35.8.  Troponin was unremarkable.  Amylase was normal.  Lipase was normal.  Magnesium was 2.1.  Chest x-ray showed a little haziness around the pericardiac silhouette.  This could be due to shaking because I do not see any infiltrates or masses.

ADMISSION DIAGNOSES

1.            Acute pyelonephritis with probable sepsis.

2.            History of gastroesophageal reflux disease, status post dilatations.

3.            Altered mental status secondary to No. 1.

4.            Dehydration.

5.            History of hypertension for 3 years.

PLAN

At this time, she is getting her IV antibiotics as I am dictating of IV Levaquin 750.  Blood cultures and urine cultures have been obtained.  Going to start her on IV fluids, normal saline at 150 mL an hour.  Will hold her diuretic.  Will start her on Protonix p.o. with her chronic reflux problem.  Will repeat labs in the a.m.  Give her electrolytes to correct some which they should.  Have discussed this with her and her husband, who are very thankful.  She also got a CT scan of head while in the ER and it was normal.

Latest Case Study - New Case Study

HISTORY

The patient is a 47-year-old male who was brought in by ambulance after his wife said he had a seizure at 4:30 this morning in the bed.  She thinks he might have had 2 more before that but did not recognize what they were.  He has never done this before.  She states he has been having problems and going to South Baldwin Hospital on Wednesday and Thursday night.  I asked her what were the problems; he had stomach pain, nausea, vomiting and his potassium was low.  She states they gave him IV fluids and potassium, but he got more tremulous every time, and she said she gave them a history that he used to have a drinking problem, but he drinks occasionally.  She is not particularly sure, she is just his significant other, and she can tell you whether he is drinking at all.  She does know that he has not been able to drink really because of his stomach hurting.  I asked they did he throw up any blood, and she said no, it was just all kind of bile at the end and no diarrhea.  When he had the seizure, she called the ambulance, and he was brought into the hospital.  In the emergency room, he had an elevated heart rate of 100, his blood pressure was 160/106, respiratory rate was 20.  He was worked up in the ER.  He underwent a CT scan of the head.  They were going to try getting an ultrasound of the abdomen because of the elevated liver function tests but were unable to complete secondary to agitation.  The ER doctor thought he was in early ETOH withdrawal.  He was transferred up to the ICU.  I was called secondary to being on unattached call.  By the time I got up to the unattached ICU, they called me within 2 hours, this gentleman is in full blown DTs, he is hallucinating.  He is agitated, has an escalated heart rate, escalated blood pressure.  He is combative and he is just nonstop motion.  I came in to see him at approximately 1:00 p.m. and patient was yelling, screaming, wanting help.  His significant other had just left the room.  He wanted her to come back because he was confused.  I did a positive string test; he said his string is gray and he is in Foley and someone needs to cut these lines off his arms; he is in restraints. 

PAST MEDICAL HISTORY

Obtained mainly from the significant other who is not the best historian because they have only been together for a year, and evidently he has been kind of secretive with all his problems to her, but she knows a lot.  

ALLERGIES

He has no known allergies.  

MEDICATIONS

He is on no chronic medication.  He was on methadone up until 3-1/2 weeks ago; she knows that.  He was being weaned from 120.  He had been weaned down to 90 milligrams and he discontinued it because he wants to get into the VA program where there is some new pain medicine that is not addicting and he can use, but he has to be off methadone, so he stopped it cold turkey.  She also states she is not sure the last time he drank.  He sneaks it around because she does not like him drinking because of his liver disorder.  I asked her what that was.  He has hepatitis C.  He also has a history of Hodgkin lymphoma.  He said he was treated in the 1980s for that; she said a year and a half ago through the VA, and I am not sure who is right.  She also says he has polycythemia vera and they have to watch his iron count.  He evidently was in Desert Storm as well, and how much of this is true from how much of what he is telling me I do not know.  He is unable to give me any straight answers at this time.  Evidently, he is legally blind in his left eye.  

FAMILY HISTORY

At this time is noncontributory. 

SOCIAL HISTORY

He and she is unsure of his last alcohol use, but said he used to be on crack drugs and lots of different narcotics, but he has not used any crack or stuff like that within 8 years.  He has had left arm surgery in the past and a vasectomy and that is about all she knows.  He does smoke about a pack a day and has been for years.  He had dental work done on Tuesday where they pulled his bottom teeth, and they put on amoxicillin for that and Mepergan.  She said he only took 2 or 3 Mepergan; they were too strong and worried about his liver, so they switched him to Lortab #12, 5 milligrams and he has taken all those in the last 3 days, but interestingly, when we did his opiate level, it was normal.   

OBJECTIVE

GENERAL/VITAL SIGNS:  When I see patient, his blood pressure is 168/112.  He is yelling, screaming.  His heart rate is 109.  He said he wants to be cut loose, and he is in back yard in Foley.  He has visual hallucinations with a positive string test.  He said the string is gray, but it changes. 

ENT:  His pupils are equal, round and reactive to light but he will not let you do much else because he starts telling me to leave him alone.  When you can calm him down and talk to him, he is somewhat distractible, but still very upset. 

CHEST:  He has bilateral breath sounds, some rhonchi. 

CARDIAC:  Tachycardic rhythm.  It is hard to tell if he has any murmur because he just keeps yelling.

ABDOMEN:  Soft but he says it has been hurting for the last few days and no one has done a damn thing about it. 

RECTAL:  Did not attempt exam at this time. 

EXTREMITIES:  No edema.   

LABORATORY DATA

On admission, his acetaminophen level is less than 10.  His opiates are negative.  His blood alcohol is less than 5.  His urinalysis shows 1+ blood, trace ketones, no white cells, no red cells.  CBC showed a white count of 8.3.  His H and H is 13.4 and 39.2.  Magnesium is 2.5.  His electrolytes plus - his sodium is 133, potassium is 2.4.  His bilirubin is 3.1.  His alk phos is 80.  His SGOT is 150, SGPT is 79.  His INR is 1.  Lipase is 91, slightly elevated.  His amylase is 86.  CT scan of the head was reported as normal.  They were unable to get the ultrasound evidently.  Chest x-ray was reported as normal.  His EKG shows a normal sinus rhythm with some baseline artifact, no prolongation of the QT interval.   

ADMISSION DIAGNOSES

1.            Delirium tremens, full blown.

2.            Ethanol withdrawal.

3.            Questionable opiate withdrawal, but he was given Dilaudid and it did not really make a difference, and he had already had 0 opiates in his urine, which I found strange since she said he has been taking Lortab. 

4.            Nausea and vomiting. 

5.            Epigastric pain.

6.            Hypokalemia.

7.            History of Hodgkin lymphoma.

8.            Hepatitis C.

PLAN

At this time, will use universal precautions.  He is going to be on a CIWA protocol.  He was given some Haldol to try controlling the agitation.  I also gave him 0.1 of clonidine and I placed him on a 0.3 clonidine patch.  The Haldol so far has helped some but not significantly.  We are going to try him on Geodon after a significant time period.  He has had replacement of his potassium with potassium jump, and we are going to repeat that and repeat his electrolytes.  Also will repeat his lipase and amylase because there is a chance he could have pancreatitis, especially with alcohol drinking, which I think is significantly more than reported.  I have talked with his significant other that he has 10% to 15% chance of mortality with him being in full blown DTs and he has probably been going through alcohol withdrawal for the last 2 to 3 days, and that is why she has been seeing him shake and tremble and throw up.  She is going to relay that to his mother and he evidently has 3 grown kids in Birmingham.  I have discussed with her that he might have to wind up on a ventilator and intubated if unable to control.  

Medical Case Studies New

HISTORY

The patient is a 71-year-old female who states Sunday evening when a storm hit, she started having nausea and vomiting.  Shortly thereafter she started having diarrhea.  She had a lot of company in for Thanksgiving but no one was really sick, including her husband and daughter and son-in-law who spent the weekend with them.  She said the diarrhea kind of stopped on Tuesday, but she has had persistent vomiting, abdominal pain and a lot of stomach bloating.  She called the office and got some Donnatal called in on Tuesday, but said it just persisted, so she came to the emergency room Wednesday.  She thought I was out of town, so she did not call the office for an appointment.  Nurses on the floor said she started having some fecal smelling material, so a G-tube was placed.  She has had 300 mL back immediately of brown colored material, and she said her stomach is feeling better, but she does not know if it is that or the pain medicine.  

PAST MEDICAL HISTORY

She has a long history of abdominal discomfort.  She had a history of pancreatitis, peptic ulcer disease and GERD.  She has had multiple dilatations by Dr. Kirby.  She has had 2 Nissen fundoplications by Dr. Weinstein.  She had a Racine procedure done in 1986 for slow liver and gallbladder dysfunction.  She has also had a lobectomy for a black spot on her lungs and a hysterectomy.  She has also had her gallbladder out.   

ALLERGIES

She is allergic to PENICILLIN, VERSED and CLEOCIN.  

CURRENT MEDICATIONS

1.            Nexium 40 milligrams a day.

2.            Lexapro 10 milligrams a day.

3.            Restoril 30 milligrams at night.

4.            Tranxene on a p.r.n. basis.

FAMILY HISTORY

Noncontributory. 

SOCIAL HISTORY

She is married with 1 child.  She has a husband of almost 50 years.  She has a 20-pack-year history of smoking but none in the last 20 years.  She does not drink alcohol at all.

OBJECTIVE

GENERAL:  When I see Ms. Jacob, she is in the bed with an NG tube in and saying her stomach is feeling better, but she says it could be the pain medicine.

HEENT:  Her oropharynx is dry, but she has had some ice chips just to keep it moist.  Her pupils are equal, round and reactive to light. 

NECK:  There are no carotid bruits. 

CHEST:  She has bilateral breath sounds distant in the bases, but she states to take deep breaths, it hurts her stomach. 

ABDOMEN:  She has positive bowel sounds but very hypoactive. 

CARDIAC:  Regular rate and rhythm with a 1/6 systolic murmur at the left sternal border. 

EXTREMITIES:  No edema.  She has multiple surgical scars on her abdomen.  

LABORATORY DATA

Includes a potassium of 3.2, glucose 133.  Her albumin is 4.0.  Calcium 9.7.  Amylase was normal at 78.  Lipase was 25.  Her white count was 11.2 with a left shift.  H and H 13.7 and 40.2.   

X-RAYS

X-ray report per Dr. Hermecz shows some air fluid levels and 1 larger air bubble of small bowel.  The ER doctor calls this partial small bowel versus ileus.  This film will be reviewed with radiology.  

ADMISSION DIAGNOSES

1.            Gastroenteritis versus ileus versus partial small bowel obstruction.  Nasogastric tube has helped. 

2.            Gastroesophageal reflux disease.

3.            Leukocytosis.

4.            Hypokalemia.

PLAN

Going to place in the hospital.  NG tube.  IV fluids.  Replace potassium.  IV Protonix.  Complete bowel rest except for ice chips.  Will repeat electrolytes, CBC and amylase in the morning along with magnesium.  She has been admitted to this hospital 2 or 3 times for the this in the past and it usually takes a couple days to resolve.  If it gets worse, will get surgical consult.