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CASE PRESENTATION
Student's Name:
Patient's Initials:
DMU
Student Number:
801-07-7280
Date of Encounter:
JAN 4, 2015
_________________________________________________________________________________
Chief Complaint:
Son report generalized weakness with left hand swelling at time for visit at nursing home.
Allergies:
NKDA
Childhood illnesses:
Benign essential hypertension, Hyperlipidemia, Hypertrophy (Benign) of Prostate with Urinary obstruc
Cardiac Pacemaker in Situ, dementia, compression fracture, dysphagia
Medications (include doses): 1) Alendronate 70mg tab 1 tablet po weekly, 14) Metoprolol succinate 25mg 1 tablet po daily
2) Aloe vesta 2-n-1 perineal skin cleanser
15) Tamsulosin hcl 0.4mg cp 1 po daily
3) Atorvastatin calcium 80mg tab 40mg 0.5 tablet po at bedtime 16) Tramadol hcl 50m
4) Buspirone hcl 5mg tab 2.5mg 0.5 tablet po bid
5) Carboxymethylcellulose na 1% oph gel 1 drop ou bid
6) Cyanocobalamin 1000mcg tab 1 tablet po am
7) Docusate na 50mg/sennosides 8.6mg tab 2 tablets po at bedtime
8) Enoxaparin 40mg/0.4ml inj 40 milligrams (0.4 milliliters) sc daily
9) Finasteride 5mg tab 1 tablet po daily
10) Furosemide 40mg tab 10mg 0.5 tablet po am
11) Latanoprost 0.005% oph soln 1 drop ou at bedtime
12) Levobunolol hcl 0.5% oph soln 1 drop ou q12h
13) Megestrol acetate 200mg/5ml oral susp 2 teaspoonfuls po bid
Surgical history:
May 17, 2013: Phacoemulsification with intraocular lens implant left eye.
November 07, 2007: New permanent pacemaker
Family history:
Older son 62: Diabetes, and hypertension
Younger son 56: Diabetes and hypertension
Unknown for parents
Social history:
Son report that he smoked around 40 years ago. Do not recall details
Review of systems:
Yes
No
SYSTEM
General:
Recent weight loss
Recent weight gain
Weakness
Fatigue
Fever
Chills
Skin:
Rashes
Lumps
Sores
Itching
Dryness
Yes
No
SYSTEM
Changes in skin color
Changes in hair
Changes in nails
Changes in size or color of moles
Yes
No
SYSTEM
Yes
No
SYSTEM
Cardiovascular
Blurred vision
Double vision
Edema
Gastrointestinal
Loss of hearing
Trouble swallowing
Tinnitus
Heartburn
Vertigo
Loss of appetite
Earache
Ear discharge
Frequent colds
Nasal stuffiness
Nasal discharge
Rectal bleeding
Nosebleeds
Sinus pain
Hemorrhoids
Neck
Constipation
Diarrhea
Goiter
Abdominal pain
Pain
Excessive belching
Stiffness
Excessive flatulence
Breasts
Jaundice
Lumps
Peripheral Vacular
Pain
Intermittent claudication
Discomfort
Leg cramps
Nipple discharge
Varicose veins
Respiratory
Ulcers
Cough
Sputum
Hemoptysis
Dyspnea
Urinary
Wheezing
Increased frequency
Pleurisy
Nocturia
Cardiovascular
Urgency
Palpitations
Flank pain
Dyspnea on exertion
Orthopnea
Hematuria
Yes
No
SYSTEM
Yes
No
SYSTEM
Urinary (Male)
Neurologic
Changes in speech
Hesitancy
Changes in orientation
Dribbling
Frequent headaches
Genital (Male)
Dizziness
Hernias
Fainting or blackouts
Weakness
Sores or ulcers
Paralysis
Testicular pain
Testicular masses
Tingling sensation
Scrotal swelling
Tremors
Involuntary movements
Genital (Female)
Seizures
Irregular menses
Hematologic
Prolonged menses
History of anemia
Excessive bleeding
Easy bruising
Excessive bleeding
Dysmenorrhea
Past transfusions
Menopause
Endocrine
Postmenopausal bleeding
Excessive sweating
Vaginal discharge
Vaginal itching
Polyuria
Musculoskeletal
Muscle pain
Joint pain
Backache
Swelling of the joints
Stiffness of the joints
Muscular weakness
Limitation of motion
History of fractures or trauma
Psychiatric
Nervousness
Anxiety
Depressed mood
Health Maintenance:
Vaccinations
Hepatitis B
Last Dose
unknown
Influenza
Measles-Mumps-Rubella
unknown
Pneumococcal
Tetanus toxoid
unknown
Varicella
not done
Last Performed
Bone densitometry
Screening
Last Performed
Lipid profile
Not done
Colonoscopy
unknown
Mammography
N/A
Diabetes screening
already +
Pap smear
N/A
Physical Exam:
Vital signs:
Temperature
Weight
Normal
Abnormal
98.2F
139
Heart rate
Height
65
5.5 ft
Respirations
Blood pressure
17
BMI
SYSTEM
General: Alert, awake, and oriented. Appropriate grooming
and hygiene. No acute distress.
Skin: Moist skin. No ulcers, rashes, or lumps. Normal hair
and nails. No jaundice.
HEENT: Normocephalic. Sclearea white. Normal visual
acuity. Pupils equally reactive to light. Normal eye fundi.
Normal ear canal. Weber midlince. Rinne AC>BC.
Normal nasal mucosa. No sinus tenderness. Moist oral
muscosa. Good dentition. No erythema or exudates.
Pain
110/60
0
ABNORMAL FINDINGS
Pace maker.
Abnormal
SYSTEM
ABNORMAL FINDINGS
Neurologic:
Mental status: Alert, awake, and oriented. Appropriate
speech. Normal mentation, insight, judgement, and memory.
Cranial nerves: Normal sense of smell. Normal visual
acuity, visual fields, and ocular fundi. Normal pupillary
reaction. Normal extraocular movements. Normal corneal
reflex, facial sensation, and jaw movements. Normal facial
movements. Normal hearing. Weber midline. Rinne AC>
BC. Normal swallowing and rise of the palate. Intact gag
reflex. Normal voice and speech. Normal shoulder and
neck movements. Normal tongue symmetry and position
Motor system: Normal muscle tone and bulk. Strength 5/5 in
all muscle groups. Point-to-point movements and rapid
alternating movements intact. Normal gait.
Sensory system: Normal sensation to pain, temperature,
light touch, vibration,and point discrimination.
Reflexes: Normal biceps, triceps, brachioradialis, patellar,
and Achilles deep tendon reflexes.
Laboratory Findings:
11.9
11.9
142
99
14.9
219
38.6
130
3.1
17.5
0.73
Segmented neutrophils
74.8%
N/A
Lymphocytes
19.8%
N/A
Eosinophils
0.1%
Alkaline phosphatase
N/A
Monocytes
5.8%
Bilirubin, total
N/A
86.4fL
Bilirubin, direct
N/A
32.9pg
Magnesium
N/A
Imaging studies:
Electrocardiogram:
99% saturation
INR 1.33
PROTHROMBIN TIME 15.8 H Secs. 11.8 - 15.0
PARTIAL THROMBOPLASTIN TIME 32.6 Secs.
[672]
22.4 - 38.3
[672]
Imaging Studies
Patient of 94y/o with history of Hypertension , old Cerebrovascular accident, dementia, BPH that was brought
to VAER due to presenting left arm with edema and hyperemia since 3 day of evolution. History was taken
from son.
At evaluation patient disoriented in time and place but oriented in person, without acute cardiopulmonary
distress, on swelling of left arm with sever non-pitting edema, and hyperemia. On CBC it shows mild
leukocitosis. This could be due to inflammatory process or normal levels for this older patient.
Most likely diagnosis, is a DVT of the left arm base on doppler, clinical presentation and limited of movement
do to pelvic tracture. Treatment will be Will admit patient due to DVT with enoxaparin, no need for IV
antibiotics due to no infections process. Will provide analgesia also. Talk to son and sign DNR due to both
sons agree in the past that patient will be DNR. Family members oriented about condition and plan and they
understand and agree. Information of possible option with anticoagulants at home was provided. Family
members understands contraindication and still deciding weatherer or not continue anticoagulation therapy
at home.
Differential diagnosis include Cellulitis, patient present with watery skin and mild leukocitosis which could be
sings of cellulites. However, imaging studies confirm the presence of incomplete compression and partial
flow in the left axillary vein with nonocclusive thrombus. And watery skin could be do to skin fragility due to
patients age. Superficial Thrombophlebitis could be another differential diagnosis, but occlusion of left axillary
vein, and not in a superficial vein, is present. Trousseaus syndrome, is highly unlikely due to the presence of
single DVT and not in multiple extremities. Nerveless, patient age is a risk factor for any cancer, not only
pancreatic types.
Currently patient is on a INR of 1.33, PT of 15.8 S , PTT: 32.6 S. INR and PT are slight elevated. Both are
used to measure Activation of extrinsic pathway. LMWH does not prolong aPTT; minimal prolongation of ACT
may be observed. Routine coagulation monitoring is not required for this patient. However, during treatment
the peak anti-Xa level (not to exceed 1.5 Units/ml) is determined 4 hours after the 3rd dose. The trough level
(>0.5 Units/ml) is determined before the 4th dose. The test is performed in the UMass-Memorial laboratory.
Plan:
Take vitals every 8 hours, limit activity only to bed rest, have the nursing personel to visit patient every 8
hours. Give a low sodium diet. Measure Input and output of liquid daily.
References:
STUDENT SIGNATURE: