🚀 go-pugleaf

Please note that this is being posted to several groups- all replies
must go to the groups, as I will not hand out individual answers this
time!

ck

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?

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?)

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?

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

(BTW, this is NOT a live case, but a montage of several that I have
attended over the last ten years. Will try to keep track of all
replies to the groups, and feed appropriate info back. Again, NO EMAIL
responses will be answered! This is to prevent dumping critical
information to only one part of the audience.)

Charles S. Krin, DO FAAFP KC5EVN, Member, PGBFH
remove "nospam*" in the "from" address to reply
"Reckless, Hell! I hit jus' where I was aimin'"
   "Bubba Shot the Jukebox!" Mark Chestnut, 1995