🚀 go-pugleaf

OK, here's the first set of responses. 
>> 35 year old black male presents to the emergency department at your
>> hospital  .... with complaints of weakness and nausea. 
>For how long? 
problems have been increasing over the last several days.
>Any emesis with the nausea?
no
> Dizziness?
no
> Chest pain?
minimal, described as heartburn
>Bowel/bladder changes?
some loose stools, one or two a day.
>> 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?
He has previously been on Clonidine 0.2 mg po tid and
Hydrochlorthiazide 25 q am

>Has he ever been hospitalized before for his HTN? for anything?
 He has been hospitalized multiple times for problems related to poor
nutrition and hypertensive urgency.'

>> 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?
Sputum is scanty and thick, rusty brown. Smokes up to three packs a
day of "OP's" when he can get them. No history of asthma.

>>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, 
O2 2 lpm per nc started. Pulse ox on Room Air 85%, increases to 90%
after O2 started
>EKG immediately!!!
Shows sinus rythm with occasional PVC's

> Place a hep lock and draw labs.
Done. 
>> Head is atraumatic, PERRLA, EOMI. Mouth is moist with poor dentition
>> and bad halitosis.
>Is that "bad halitosis" or FOUL?
Foul, and it persists when the patient is breathing through his nose 
>> 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? 
Recent HIV testing at the TB clinic was negative, but he has completed
a 6 month course of observed triple drug therapy.
>> 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?
right- however there's a hint above as to where you can find more
history- time is now 1000 hrs on a Tuesday morning. 
>> 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
All of which are good working diagnoses, but there are a couple of
addtional ones that you have missed despite a flare lit history.
> 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.
Ekg above, others pending.

ck