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Np Virtual rounds

Np Virtual rounds. March 9, 2010 Case Studies. Case Study 1. 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

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Np Virtual rounds

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  1. Np Virtual rounds March 9, 2010 Case Studies

  2. Case Study 1 • 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

  3. History • 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

  4. Differential diagnoses • Other history questions? • Beginning list of differentials? • What are the things we don’t want to miss? • Considering she is a young woman • i.e. Pulmonary embolus,spontaneous, pneumothorax, pneumonia, cardiac, menigitis

  5. Physical Exam • 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

  6. Differentials • Further physical history? • Differentials any different/narrowed down? • What can we do today or within next 24-48 hours?

  7. What I did • 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

  8. Follow up visits • 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

  9. Discussion • Other considerations • Graves – antithyroid antibodies 140 need to r/o autoimmune disorder • Goitre • Hashimoto’s • Other medications/management considerations

  10. Case Study 2 • 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

  11. HP1 • 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

  12. Management • 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

  13. Management • 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

  14. Discussion • Diagnostics • Medications • Management

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