Ophthalmology Case Study

HISTORY
Patient is a 24-year-old female who was admitted through the Emergency Department to my service on ______ call.  I was called at approximately 11 p.m. on the night of admission.  She was admitted for pyelonephritis and right adnexal mass and nausea and vomiting.  She states on Wednesday she started having right sided back pain, on Thursday she got fever up to 101.6 that had come and gone and by Thursday evening to Friday a.m. it was hard to urinate.  She has a history of kidney stones.  Most recently she passed one 4 months ago through Thomas Hospital ER.  She was given some medicines at home and she passed the stone, so we did a CT scan on her thinking may be she had no stone.  When she was brought to ER there was no evidence of stone, but she did pickup a right adnexal mass per ER report of 5 x 7 cm.  She was examined and did not feel to have PID. When we got a blood work back her white count was slightly elevated but then she was noted to have a very cloudy urine with lots of white cells and this is most consistent pain with pyelonephritis.  So I am not sure this lady had obstruction earlier when it is hard to urinate or went on.  When I see patient she is in lot discomfort in right flank.  She was surprised about the mass in her adnexa.  She has already seen _____ in consultation.  We discussed differential diagnosis but ______ has done this as well.

PAST MEDICAL HISTORY

She is allergic to penicillin from a GI standpoint.  She also gets a rash with Demerol.  She is on chronic medication.  She has been hospitalized once for vaginal delivery of her 3-year-old son.  She also had a bilateral tubal ligation after this for postpartum hemorrhage she was told.  She is divorced for a year.  She has had no other surgeries.

FAMILY HISTORY

Mother and grandmother had questionable ovarian cancer and there is diabetes in the family.

SOCIAL HISTORY

She has moved to this Eastern Shore Area  8 months ago.  She is divorced for a year.  Her son lives with her, 6 months, and her ex-husband for 6 months.  She lives down here with her "adopted mom" some lady met she met 2 years in Indiana and they moved down here together.  She has just taken a job 3 months ago as a manager of the Pizza Hut in Daphne.  She does not smoke, does not drink.  She states she is married 2 years prior.

OBJECTIVE

GENERAL:  When I saw the patient, she is complaining of lot of pain and says that she gives up, she feels nauseated.  Said even though she is hurting and nauseated, she still want to work everyday at Pizza Hut and even worked yesterday Friday.

ENT EXAM:  She has a dry oropharynx.

NECK:  Supple.  No meningeal signs.

CHEST:  She has bilateral breath sounds clear to auscultation.

CARDIAC EXAM:  Revealed a regular rate and rhythm without ectopy.

ABDOMEN:  She has positive bowel sounds.  She is tender in the right flank and her right pelvic region.  This really is making her abdomen hurt, but she admits it is mainly on the right and mainly in her back that hurts the worst.

EXTREMITIES:  No edema.

LABORATORY DATA

As mentioned she had urinalysis from last night at 10 o'clock.  Within 10 hours she has already grown out E. coli greater than 100,000 count.  Her urinalysis last night showed 3+ blood, positive nitrates, positive leukocytes, she has 2150 white cells with mini bacteria, white count was only 9.7 with a slight left shift.  H and H was 12.0 and 34.1 respectively.  Serum pregnancy test was negative.  Multi-chem plus, only abnormality was her potassium 3.3, her BUN and creatinine ratio was only 1:9.

ADMISSION DIAGNOSES

1.            Acute pyelonephritis.  Urine culture obtained.  She is on IV Levaquin.  We are going to discontinue Bactrim that was given in the emergeny room since she has had some nausea and vomiting.

2.            Right adnexal mass, I appreciate consult with ______ and his input.

3.            Hypokalemia.

4.            Nausea and vomiting.

PLAN

Continue the IV fluids to replace the potassium.  Continue antibiotics till culture and sensitivities come back.  I explain to her this might take 2 to 3 days of hospitalization and her fever will spike.  She was told that she might be get some fluids and go home the next day, but she is still vomiting.

 

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.

Ophthalmology Case Studies

HISTORY

Patient is an 81-year-old male who presents to my office for recheck of his iron, but he states during the early morning hour, he get chills, shakes.  His wife checked his temperature about 5 and it was 99 plus and about 5:30, he started burning up, and she checked his fever is 101.6, and he was sweating.  He said he has had a little cough, but he had not feel bad.  He said he has been feeling actually pretty good.  He was here for recheck of his anemia initially and also he got clearance to go on O2 to up in Washington DC via flight.  At my seen, he was sitting on a wheelchair.  He has his 2 liters oxygen on.  He is hypoxic.  We increased it to 3.  His O2 sat was 85%.  His chest has congestion left base and middle lobe much more than the right.  He cannot getting this up though, we increased his O2 to 4 liters.  He was given breathing treatment.  He sat actually dropped to 81 ______ treatment he was having hard time getting his breathing.  He has got to breath deep and he got back up to 84% to 85%.

PAST MEDICAL HISTORY

He has severe COPD, that is followed by myself and Dr. Goetter.  He has been in the Birmingham for research program, but he was turned down.  He is depended on O2 continuously.  He also has a history of BPH, history of renal stones, and history of hypertension.

CURRENT MEDICATIONS

His current medications are numerous, included: 

1.            O2.

2.            He is on DuoNeb 4 times a day per nebulizer.

3.            He has albuterol for rescue every 3.

4.            He is on prednisone 10 milligrams a day.

5.            He is on theophylline 400 milligrams a day.

6.            Spiriva 18 micrograms a day.

7.            Advair Diskus 500/50 b.i.d.

8.            He is on Lasix 1 a day.

9.            Aldactone 50 milligrams a day.

10.          Avodart 1 a day.

11.          Hytrin 5 milligrams a day.

12.          Zocor 20 milligrams a day.

13.          He is on Restoril 30 milligrams at night.

14.          He is on Protonix 40 milligrams a day.

15.          He takes B12 monthly.

16.          He takes Mucinex twice daily.

17.          He takes magnesium citrate p.r.n.

18.          MiraLax twice a day.

19.          He has been recently started on iron sulfate after Dr. Ives did a workup and really just found diverticulosis, but no significant pathology.

FAMILY HISTORY

Noncontributory at this time.

SOCIAL HISTORY

He is married.  His wife is 20 plus years younger and takes very good care of him.  He is without cigarettes for the past 9 years, but prior that he has about 100 to 120 pack a year history of smoking.  He drinks occasionally bourbon.

OBJECTIVE

VITAL SIGNS:  Patient's blood pressure is 90/52.  His pulse 104.  He looks into be mild to moderate respiratory distress.  He states once he breath deep, he can do okay in a wheelchair, but if he gets up a while he is severely short of breath.

HEENT EXAM:  His oropharynx is somewhat dry.  Oxygen in place.  TM has hearing aids in place, otherwise looks okay.

CHEST:  He has bilateral breath sounds or congestion noted in left base and left mid lung.  Decreased breath sounds in the right, which is more of his chronicity.

CARDIAC:  He has tachycardic rhythm at 104 to 108.

ABDOMEN:  Soft.  He has positive bowel sounds.  He has 1+ edema in his lateral plateau.

He has lots of superficial bruising and ecchymosis on his arms and legs.

ADMISSION DIAGNOSES

1.            Chronic obstructive pulmonary disease exacerbation.

2.            Hypertension.

3.            Chronic renal failure.

4.            Anemia.

5.            Benign prostatic hypertrophy.

6.            Hyperlipidemia.

7.            Advanced age.

8.            Probable cor pulmonale.

PLAN

At this time, I am going to admit to the hospital, start him empirically on IV Levaquin 750 daily.  He had a PA and lateral chest x-ray.  Resume his home meds except for his diuretics with his pressure being low, "supplement O2."  Nebulizer treatments every 6 round the clock every 3 p.r.n., continue the Advair.  We will check CBC, electrolytes, sputum and blood cultures.  He is DNR at his request.

Ophthalmology Case Study

HISTORY OF PRESENT ILLNESS

Mr. Bass is a 42-year-old white male who came in with chest pain.  He states occurred approximately 5 p.m. yesterday.  He had associated shortness of breath.  He described the chest discomfort as a pressure-like sensation in his left chest radiating to his left upper arm.  It has been intermittent with sharp pain and it has associated shortness of breath and diaphoresis.  He was here a couple of weeks ago for shortness of breath after an exertional episode.  The patient is a policeman and he was chasing someone.  He could not get his breath back.  He was evaluated and had respiratory treatments and states he felt better.  He has no documented history of coronary disease.  He has had foreign travel within the last 6 months.

MEDICATIONS

Include: 

1.            Zestril 20 a day.

2.            Protonix 40 a day.

3.            Advair inhaler.

4.            Celexa 40 a day. 

ALLERGIES

None known.  

SOCIAL HISTORY

Patient does not drink or smoke.  He does not take drugs.  He is married and lives locally, works with the police department.   

FAMILY HISTORY

Mother had coronary disease and bypass at age 48.  

REVIEW OF SYSTEMS

GENERAL:  No fever, chills, weight loss, syncope.Positive for episodes of dizziness.  EYES: No vision changes.  ENT: No hearing changes, dysphasia.  CARDIOVASCULAR:  Positive for chest pain and shortness of breath as described.  No palpitations, PND, pedal edema.  He does have diaphoresis.  RESPIRATORY:  No sputum, cough, hemoptysis, wheezing.  He did have an episode of shortness of breath a couple of weeks ago as well.  GU: No nocturia, polyuria, frequency.  GI:  No nausea, vomiting, diarrhea, hematochezia, hematemesis.  MUSCULOSKELETAL: No arthralgias, myalgias.  SKIN:  No cyanosis, rash, ulceration.  PSYCHIATRIC: No depression, anxiety.  NEURO: No weakness, TIA, seizures, headaches.  ENDO:  No thyroid disease.  IMMUNOLOGIC: No infectious disease, night sweats.  HEMATOLOGIC:  No bruising or bleeding.  All other review of systems remained negative.  

PHYSICAL EXAMINATION

VITAL SIGNS:  Blood pressure 132/84, heart rate 86, respirations 20, weight 230.  HEAD, EARS, EYES, NOSE, AND THROAT:  Pupils equal, round, reactive to light and accommodation.  Mucous membranes pink and moist.  NECK:  Supple without masses.  Jugular venous pressure appears normal.  Carotid upstroke is brisk without bruit.  HEART:  Rhythm is regular.  S1, S2 are normal.  There are no murmurs, gallops, rubs noted.  LUNGS:  Clear to auscultation bilaterally.  No wheezing, rhonchi, or rales.  ABDOMEN: Soft, nontender.  Bowel sounds present in all quadrants.  EXTREMITIES:  Show no clubbing, cyanosis, edema.  Peripheral pulses intact.  NEURO:  Intact.  

LABORATORY DATA

CT of the chest was normal.  D-dimer 134; CK 124, 94; MB 1.3, 1.1, cTnI 0.04, 0.02.  Sodium 138, potassium 3.7, chloride 106, bicarb 28, BUN and creatinine 17 and 1.4, glucose 99.  WBC 6.9, H and H 16.1 and 46.5, platelets 171.  

EKG: Sinus rhythm with ventricular rate 96, no other acute ST and T-wave changes noted.  

IMPRESSION

1.            Chest pain.  Enzymes negative for 2 sets.  D-dimer negative.  Chest CT normal. 

2.            Hypertension. 

3.            Strong family history of coronary disease. 

4.            Foreign travel within 6 months. 

RECOMMENDATIONS AND DISCUSSION

Cardiolite GXT in the a.m.Get serial enzymes and lipid profile.

Dr. Buckley, who saw, evaluated, and formulated the plan on this patient.

Ophthalmology Case Study

HISTORY
Patient is an 84-year-old male who states for the last 10 days he has had a history of upper respiratory symptoms, low-grade temp, cough, just has gotten progressively worse.  He states his shortness of breath has been there the whole time, but has gotten progressively worse as well.  He denies any chest pain, just breathing problems.  He was taking Tylenol.  The night he came in, he says it just got too bad and told his wife he needed to come to the emergency room.  He has coughed up some phlegm, but not a lot.  Before he became ill, he was going to the Y and doing pool exercises on a p.r.n. basis.  In the ER, he was noted to be in respiratory distress.  He was given O2 nebulizer treatments and they got his sats up.  ER doctor said he is very tight.  He was responding nicely to the nebulizers and he was transmitted to the floor.  He became worse during the early morning hours.  ER doctor called me.  His troponin was 0.9 when we got the lab back, and we transferred him to the ICU and repeated cardiac enzymes and he was given dose of Lovenox.  He denies having chest pain, particularly just says it is kind of tight to breathe.  He is on high-flow O2 to keep his sats up.  He has crackles and wheezes; left side is now worse than the right.  He was given Lasix in the ER and also given Lasix in the ICU.  He has diuresed somewhat and is more comfortable now.

ALLERGIES

He is allergic to SULFA.

CURRENT MEDICATIONS

1.            Cardura 8 milligrams a day.

2.            Norvasc 5 milligrams a day.

3.            He takes an aspirin a day.

4.            Aciphex 20 milligrams a day. 

5.            He takes fish oil daily.

6.            Multivitamin. 

PAST MEDICAL AND SURGICAL HISTORY

He had a total knee replacement in 1991 on the right.  He has spinal stenosis, which is moderate to severe, and that is why he is doing pool exercises.  He has had hypertension for years.  He had a TURP years ago, he cannot remember exactly when, but he still has BPH problems.

FAMILY HISTORY

At this time is noncontributory.

SOCIAL HISTORY

He has a 90 to 100-pack-year history of smoking, but he quit in 1982.  He is married.  He occasionally drinks, but not very often. 

OBJECTIVE

GENERAL:  When I see the patient, he is in ICU setting.  He is sitting at about 45 degrees, said his mouth is dry, but otherwise he is feeling okay, just got some congestion in his chest.

ENT EXAM:  His pupils are small but reactive.  Oropharynx is dry.  Lips are dry.

CHEST:  He has bilateral breath sounds with crackles on the left and the right with some wheezing noted, but very mild.  He said it was worse before he got his treatment.

CARDIAC EXAM:  Revealed a regularly irregular rhythm with a rate of 110.

ABDOMEN:  Obese.  He has positive bowel sounds.  He is nondistended, nontender.

EXTREMITIES:  Legs, he has bilateral trace edema, but this is kind of chronic in this gentleman.  Most of it is nonpitting.  There might be a little bit more on the right than left compared to normal.

LABORATORY DATA

Include a brain natriuretic peptide of 499.  His CMP showed elevated sugar of 181, this is nonfasting; fasting is 3.7.  His white count was 13,700 with a left shift.  H and H 12.6 and 38.6 respectively.  His initial troponin was 0.96.  CPK was 506.  Repeat troponin came back at 2.19 with CPK of 473.  Chest x-ray showed bilateral infiltrates.  This needs to be reviewed.  EKG shows atrial fibrillation with decreased forces in the anterior chest leads.  

ASSESSMENT

1.            Respiratory distress, most likely pneumonia, now complicated by congestive heart failure.  This could be aggravated by a subendocardial myocardial infarction or new-onset myocardial infarction.

2.            New-onset atrial fibrillation with increased troponin.

3.            Hypertension.

4.            Benign prostatic hypertrophy.

5.            Spinal stenosis.

PLAN

At this time, he is going to stay in the ICU.  We will consult cardiology along with critical care.  He was given Lovenox and this will be continued with his new-onset atrial fibrillation.  He is on Levaquin, increased to 750 IV daily.  He is on nebulizer treatments O2.  He has been given some dig to try to slow his rate down.  With his amount of bronchospasm, would stay away from beta blockers.  Will discuss with cardiology.