🚀 go-pugleaf

In article <33775b5f.185040168@news.iamerica.net> Charles S. Krin,
Nospam*ckrin@Iamerica.net writes:
>35 year old black male presents to the emergency department at your
>hospital (OK, you medics out there are just going to have to pretend
>you are doing in house time for this one- the nurses had to make a
>home visit with the last one!) with complaints of weakness and nausea.
>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.
>
>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, 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. 
>
>Head is atraumatic, PERRLA, EOMI. Mouth is moist with poor dentition
>and bad halitosis.
>
>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?

Temp?

Just try to get as much history as you can with the idea that the patient
may not be able to answer many questions.  Use old chart to get futher
info.

Onset, duration, getting worse or better, exacerbating factors, tempo of
changes........

Any other drug use other than ETOH?  HIV risk factors?  PPD+?  Last
Drink?  NSAID use?

Presence of fever/chills, vomiting (hematemesis or any recent emesis), 
black stools, PND, orthopnea, chest pain (pleuritic, with exertion,
ratiations), pain in calfs, hemoptysis, color of sputum, change in the
color or amount of urine.  

And general ROS.

What other medications is he taking, and does he ever take them.

Has he ever had this problem before?

Past medical history.




>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?)


No much.


>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?

Get old chart!

CHF (from ETOH or MI) vs liver failure vs pneumona (high risk aspiration
vs other) vs SBP.



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

Pulse ox now.
Then...
CBC/Dif/lytes/BUN/Cr/LFTs/albumin/ammonia/ECG/UA/Utox/CXR/ABG/Blood
ETOH/chem panel.




Matt