🚀 go-pugleaf

> 35 year old black male presents to the emergency department at your
> hospital  .... with complaints of weakness and nausea. 
For how long? Any emesis with the nausea? Dizziness? Chest pain?
Bowel/bladder changes?

> He is well known to your facility as a homeless person dependent on
> the ED for all of his medical care. Past medical history includes
> alcoholism and hypertension. He states that he has been out of his
> medications for several days.
WHat meds? When was last dose?
Has he ever been hospitalized before for his HTN? for anything?
 
> He states that his appetite has been down for several days, but denies
> increased alcohol consumption, beyond his normal 2 pints of
> "Thunderbird" per day. Further questioning reveals a moderately
> productive cough,
Color, quantity of sputum? Smoker? Asthma history?

 2 pound weight gain since last visit three weeks
> ago.
> 
> Physical exam shows B/P 100/60 seated, pulse 100, respirations 35 with
> 1 sentence dyspnea.
Get some O2 on him immediately. Pulse oximetry, EKG immediately!!! Place
a hep lock and draw labs.
> 
> Head is atraumatic, PERRLA, EOMI. Mouth is moist with poor dentition
> and bad halitosis.
Is that "bad halitosis" or FOUL?
> 
> Lungs show marked rales bilaterally with decreased breath sounds.
> Heart is mildly tachycardiac, regular rate and rythem without murmurs,
> gallops or rubs.
> 
> Abdomen is soft and non tender with mild tympany and distention. No
> obvious masses are found on palpation, but the liver margin is found
> behind the costal margin.
> 
> Genitalia shows moderately atrophic testes, otherwise normal
> uncircumcised male. Rectal shows marked hemorrhoids.
> 
> Extremities show moderate clubbing, minimal cyanosis and 2 + pitting
> edema.
> 
> Weather has been in the high 70's during the day, dropping to the 40's
> overnight. He is dressed in a heavy, ragged coat, and shivers in the
> 65 deg. exam room. While you are talking to him, he is occasionally
> looking off to either side, and asking you to repeat your questions.
> 
> Question 1: What further information do you want to try to obtain on
> the history?

See above...and I'm sure that I'm missing some biggies..HIV status? TB
status? 

> Question 2: How much can you depend on any history he gives you that
> is not previously documented? (by the same token, how much can you
> depend on the old documentation obtained from the patient which is not
> backed up by family or professional observations?)
Probably little to none, but it's the "best you've got" right?
> 
> Question 3: What is your working assessment, and what do you want to
> do while waiting for the doc to arrive and re evaluate the patient?
> Wouldn't be comfortable with diagnoses yet, but my "BIG #" differential would include:
1- CHF
2- Pneumonia
3- PE

> Question 4: What lab work or tests would you want to have ready to
> roll by the time the doc gets there?


 CBC, PT/PTT, ABGs, SMA-20 to include LFTs & amylase.  Chest X-Ray, EKG.

Great case study! Thanks...THIS is what this group needs more of...and
less WHINING (of course, that's just MY humble opinion, and
"smallchange" probably feels differently...but ain't that the beauty of
America? 
Keep pounding out the case studies!! 

Andrew A. Galvin RN, CEN 
ENP-Student