March 9, 2010Case Studies

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

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

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

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

Further physical history? Differentials any different/narrowed

down? What can we do today or within next 24-

48 hours?

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

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

Other considerations Graves – antithyroid antibodies 140 need

to r/o autoimmune disorder Goitre Hashimoto’s Other medications/management

considerations

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

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

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

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

Diagnostics Medications Management