🚀 go-pugleaf

this is the fifth post from me in this series. Lab work will be posted
monday 12 may am.

ck

On 11 May 1997 14:21:44 GMT, Matthew A. Emme
<emme0002@gold.tc.umn.edu> wrote:

>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?
prev posted
>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.
prev posted
>Onset, duration, getting worse or better, exacerbating factors, tempo of
>changes........
prev posted
>Any other drug use other than ETOH?  HIV risk factors?  PPD+?  Last
>Drink?  
prev posted
>NSAID use?
takes occasional doses of asprin when he can get them.

>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.  
prev. posted- no frank hemoptysis has been noted, multple myalgias are
noted, he has little bladder control.
>And general ROS.
prev posted

>What other medications is he taking, and does he ever take them.
prev posted.
>Has he ever had this problem before?
not recently, but multple admits for problems related to hypertension
and poor nutrition

>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!
volume 4 of 4 is already 3 inches thick. Where do you want to begin?

>CHF (from ETOH or MI) vs liver failure vs pneumona (high risk aspiration
>vs other) vs SBP.
good start but everyone is still missing something major.
>
>
>>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.
prev posted
>Then...
>CBC/Dif/lytes/BUN/Cr/LFTs/albumin/ammonia/ECG/UA/Utox/CXR/ABG/Blood
>ETOH/chem panel.
pending

>
>
>
>Matt