Transcript Np Virtual rounds

March 9, 2010
Case Studies
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32 y/o woman presenting to clinic last Monday
w/ sudden onset of weakness, sob, chest pain,
severe headache w/numbness in arms and hands
particularly on L side while hiking the previous
afternoon
She managed to get herself home w/ great
difficulty – shaking, teeth chattering – bit her
tongue, speech difficulty at the time, had hot bath,
began to feel better, no other home tx
Most sxs resolved in a few hours but woke with
ongoing weakness and L chest pain that brought
her to clinic
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Normally well, active & healthy woman w/ no previous
episodes of chest pain, sob, headaches
HPI – no previous episodes of
cp/sob/numbness/weakness, some fatigue/dysthmia, wt
loss ~6 lbs in 1 mo, oily skin more than normal, no recent
illness, family healthy,
ROS unremarkable
PMH – no CD, no surgeries/trauma, updated
immunizations, significant MH hx, IBS, hx rectal bleeding,
normal colonscopy, low Fe in past, no gyn issues
FMH – no hx heart disease, thyroid, neuro
Medications – none, no other otc/street/etoh, no allergies
Social hx - non smoker, no recent travel, recent move to
Cortes – move frequently, 1 son age 3, husband is teacher
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Other history questions?
Beginning list of differentials?
What are the things we don’t want to miss?
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Considering she is a young woman
i.e. Pulmonary embolus,spontaneous,
pneumothorax, pneumonia, cardiac, menigitis
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T 36.8 BP 102/60 HRR 100 RR 20
Appearance – calm, quiet affect, doesn’t appear in
acute distress, alert & oriented x 3, appropriate
responses to conversation
Neuro assessment – CNII-IX, gait, proproception,
sensation, DTRs,visual acuity all within normal
limits, no ocular manifestations
MSK – u/l extremities ROM/strength wnl
CVS – bit tachycardic S1/2, no S3/4, no
murmurs/bruits/JVP
Chest – CTA Abd exam unremarkable
HEENT – unremarkable aside from enlarged
thyroid
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Further physical history?
Differentials any different/narrowed down?
What can we do today or within next 24-48
hours?
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Reviewed care for next 24 hours including
management of chest pain
Blood work and ECG on Wed morning
US of thyroid
f/u visit in office Wed afternoon
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Wed am follow up – normal ECG, HR increasing
tachy at home – one episode of chest pain Tues
chose not to attend clinic
Wed blood work results: TSH 0.01 T3 20.4 T4 36,
ferritin 15 – phoned pt w/ results, assess status
Thurs am visit admits to daily chest pain episodes,
dysthmia for several months, no suicidal
ideation/depression – started on propranolol &
iron supplement - consulted w/ pharmacy & GP
re dosing – difference of opinion
U/S to r/o malignancy
Referral to endocrinology
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Other considerations
Graves – antithyroid antibodies 140 need to r/o
autoimmune disorder
Goitre
Hashimoto’s
Other medications/management
considerations
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96 y/o woman w/ multiple presentation of
cellulitis over several months
Initial treatment w/ keflex successful
Subsequent infections not as successful
w/antibiotics
Consideration of her age and co-morbidities at
each stage of treatment
Locum physicians perspective of management
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Patient managed at home by daughter, 2 years
ago living independently, was driving
Last winter pneumonia – local hospital
management inadequate – increasing
sedentary, outings minimal
PMH: diabetes, HTN, mild CKD, psoriasis,
plantus lichen
Meds – glicazide, metformin, ramipril,
ointments for psoriasis
Allergies - pencillin
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6 weeks management at home/frequent visits
to clinic as dgt declined HNC
Cloxicillin po – for cellulitis – beginning to
think dealing w/ arterial wound as start to
debride a large weeping psoriasis patch R
anterior ankle
Increasing sedentary, sleeping alot, increasing
pain, redness, non-healing wound
Threatened limb – to local hospital – switch abx
sent home
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Home – ongoing discussion of level of
intervention w/ pt & dgt
Consultation w/ locums, radiology re:
management
Review of co-morbidities
Lab work/other possible investigations
Arterial wound – worsening fluid balance and
leg edema
What we did – then what happened
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Diagnostics
Medications
Management