🚀 go-pugleaf

Additional question: what is the first thing that you want to do with
this patient, both for your comfort and his protection?
ck
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

> 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

On Fri, 09 May 1997 17:39:03 GMT, Nospam*ckrin@Iamerica.net (Charles
S. Krin, DO FAAFP) wrote:

>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!
incidently, I will be monitoring all of the groups, so feel free to
post just to one to save band width!
ck

snip
>
>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.
PERRLA=Pupils Equal, Round and Reactive to Light and Accomdation
EOMI=Extra Ocular Muscles Intact

someone's already had a problem with acronyms!

ck

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

Hello..

Nospam*ckrin@Iamerica.net (Charles S. Krin, DO FAAFP) wrote:

>Question 1: What further information do you want to try to obtain on
>the history?

Medications, how long homeless, how long has he been drinking and when
was his last drink?  Any drug abuse? Last bowel movement and color,
color of urine.  Any splenomegaly or scleral icterus?  Any night
sweats?  Does patient have contact with any relatives and if so, can
they furnish better/more info or offer help?

>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?)

Take it with a grain of salt.

>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?

ALD and ascites, possible TB.  Start nasal O2, restrict salt and fluid
intake.  Counsel patient to get help to quit drinking.  Monitor for
signs of withdrawal. 

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

SMAC20, H&H, LFTs,  Albumin, Bili, Sputum Culture for AFB, EtOH level.

>(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.)

-Mike-

This is the sixth post from me and lab work results are included. but
first:

>Would try to determine if the patient had and episode of chest paint,, and
>in the already mentioned labs I would include serum ketones, and lactic
>acid level. (these may have already been ordered I may have missed them) 
see below
>And I would if not already done determine try orientation.  There is
>changes noted in his attention span so I would investigate this. Not sure
>if this has been established, but would assess the abdomen better, maybe
>since he has not taken his coat off yet,it has not been established the
>size (fluid) of his abdomen which could be causing a lot of his complaints,
>and if their is any bowel sound (obstruction????)  Also, chech his
>peripheral pulses.  May need to do a CT, head and abdomen if no finding
>seem to come up from lab work.

Orientation is fair to good- he knows who he is, where he is, and what
month it is. He continues to be easily distractable, occasionally
making off the wall comments over your shoulder.

The patient is stripped and bathed (That's the order I was looking
for: "Bath, STAT!")- multiple bruises and scabs are noted along the
arms, legs and back. Liver is still noted to be under the costal
margin, and there is little fluid wave. Bowel sounds are quiet.

it is now 1200 hrs, tues am.

Lab work:

CBC: 15,700 WBC with 80 neut, 10 band, 5 lymph, 5 eos, hgb 9.4, hct
28, mcv 108

SMAC panel : Ca 8.0, Mg 2.0, P 3.4, Glucose 110, BUN 50, Creatinine
3.0, Uric Acid 11.0, Triglycerides 230, Cholesterol 90, T bili 3.0, D
bili 2.0, T protein 7.0, Albumin 2.5, Alk Phos 200, LDH 500, AST/SGOT
450, ALT/SGPT 500, CPK 1000, Na 115, K 3.0, CO2 15, Cl 100, 

CK-MB fractionate= 50 (5%)

Lactate levels are pending

Blood alcohol 0.15%

Ketone small positive

EKG already posted.

CXR: bilateral lobar infiltrates worse on right side with cavitating
lesion seen in the right base.

repeat ABG on O2 after hydration: pH 7.35, CO2 40, O2 65, sat 89%

Breathing is noted to be somewhat more labored.

What do you want to do now?

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

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

Charles S. Krin, DO FAAFP <Nospam*ckrin@Iamerica.net> wrote in article
<337c3345.6911507@news.iamerica.net>...
> This is the sixth post from me and lab work results are included. but
> first:
> 
> >

Okay, Okay, Lets treat this guy's Anerobic Pulmonary Abcess and get back to
bed!

                                                       ---RES

Ah, Dr Krin, you left out the neuro exam.  Does he have sign of
neuropathy?  Does he have delayed deep tendon reflex release?  What is
his auditory acuity?  Does he have any hallucination?  Any tremor?

The salient feature is profound dyspnea with bilateral crackles and
pedal edema, cold intolerance, auditory/visual acuity loss, clubbing,
irritability, mild jaundice.  Based on info supplied so far, some of the
considerations are:

(1)Non-ETOH stuff (ETOH is a red herring)
A. Hypothroidism/Myxedema (cold intolerance, hearing acuity change,
edema)
B. Grave's. (CHF, clubbing, irritability, tachycardia)
C.  Others: pneumonia, P.E. >>> I really doubt. That would be too
boring.
D.  HIV (e.g. PCP)/ TB type of stuffs.  Lower on my DDx but must be kept
in mind.

(2)ETOH
A. Beriberi and thiamine deficiency (edema+ crackle + SOB suggests CHF. 
In this scenario thiamine deficiency is commonly seen in case
presentation if not in real life.)
Does he have neuropathy?  
B. ETOH cardiomyopathy
C. Liver failure>>>renal failure>>>fluid overload
D. Methanol/ethylene glycol ingestion with renal failure.  What is in in
that "Thunderbird" bottle?  Is it just a cheap wine or is there
something else?  What do you smell?
 
Additional historical items: where and how did he get his booze? The
duration of his dyspnea and pedal edema as well as probable ascites? 
Took anything else, like cocaine?

In addition to the usual stuffs (SMA20/CBC/Osm, u/a, ABG, stat CXR, EKG,
iv, oxygen, rhythm and sat monitor), we need to get tox screen, alcohol
levels (ethanol,methanol, and ethylene glycol), thyroid tests.  He needs
thiamine as well as other vitamins.  Cardiac echo to document heart
function would be nice, but then he has no insurance so it may be tough
to get and this could wait.  


Paul Lee