CASE PRESENTATION
Student's Name:
Patient's Initials:
MRW
Student Number:
801-07-7280
Date of Encounter:
JAN 4, 2015
_________________________________________________________________________________
Chief Complaint:
Allergies:
NKDA
Childhood illnesses:
Surgical history:
Family history:
No prior CHF, No prior MI, No prior CABG, No prior PCI, No prior Cardiac Cath,
No prior Valve Surgery, No prior Valve Treatment (TVT),
No prior Cardiac Transplant
No prior CHF, No prior MI, No prior CABG, No prior PCI, No prior Cardiac Cath,
No prior Valve Surgery, No prior Valve Treatment (TVT),
No prior Cardiac Transplant
Social history:
No history of tobacco, alcohol abuse or illicit drug use.
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
unknown
Measles-Mumps-Rubella
unknown
Pneumococcal
unknown
Tetanus toxoid
unknown
Varicella
unknown
Last Performed
Bone densitometry
Screening
Last Performed
Lipid profile
N/A
N/A
Colonoscopy
N/A
Mammography
N/A
Diabetes screening
N/A
Pap smear
N/A
Physical Exam:
Vital signs:
Temperature
Weight
Normal
Abnormal
97.6F
192
Heart rate
Height
52
5.8 ft
Respirations
BMI
SYSTEM
18
29.3
Blood pressure
Pain
138/60
0
ABNORMAL FINDINGS
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:
15.3
10.0
139
99
17.3
219
44.5
202
4.6
27
0.8
Segmented neutrophils
81.2 %
13
Lymphocytes
10.8 %
14
Eosinophils
2.8 %
Alkaline phosphatase
65
Monocytes
5.0 %
Bilirubin, total
0.79
89.0fL
Bilirubin, direct
N/A`
30.6pg
Magnesium
1.73
Imaging studies:
Electrocardiogram:
Imaging Studies
MRW is a 76 year old male with history of diabetes mellitus, CAD, intermittent claudication, hypertension and
hyperlipidemia presents to emergency department, with shortness of breath and chest pain. was evaluated
today at bed side. Vital signs were evident of bradycardia. Physical exam were positive for left basilar
crackles, abdominal hernia, and benign rest of exam. ECG with high degree AV block, negative
chronotropism. Patient at the moment asymptomatic, referring he was feeling better than when he arrived.
Labs with leukocytosis, stable hemoglobin and platelets. Chem profile with stable renal function and no major
electrolyte abnormalities. Probnp elevated at 3202. Due to AV block, patient was started on telemetry, and
bedside cardiac defibrillator on pacemaker mode placed.
Base on clinical and ECGs findings, most likely diagnosis is AV complete block. Patient with fatigue and
dyspnea that could be secondary to this block. Patient's previous ECGs showes rates over 60s and without
AV block. Patient at the moment of evaluation at IM ward referred no symptoms and had stable vital signs
despite bradycardia. Treatment is pacemaker placement. Therefore temporarily a bedside monitor in
pacemaker placed. Patient had metoprolol ordered at the ER, however never administered, it was quickly
discontinued.
Patient could also develop a panic attack, patient with shortness of breath that started after inciting event of
his dead wife's memories. In association with extreme nervousness, feeling of wanting to die, and lack of
sleep. Patient's wife died 4 months ago, which put him in a labile state, precipitating panic panic attack.
Patient's elevated blood pressure episode can be related to emotional stressor, and is now resolved. Patient
did express feeling extremely sad and having ideas of killing himself by stepping up a stairway he has at
home and throwing himself down. Therefore patient started on constant observation and psychiatry
consulted.
Differential diagnose could be CHF or CAP base on CXR possible edema on the lungs. However, patient did
not present with volume overload (JVD, bilateral crackles, peripheral edema) and could lay down in his bed
flat in supine position. CAP is also unlikely because patient denied cough, he has not had fever, however, he
does present with borderline high leukocytosis. CXR does not rule out any infectious or effusion. Therefore
base on the lack of CAP symptoms, antibiotics were not ordered.
Echocardiogram was ordered. Last echo from 2010 with preserved diastolic and systolic function.
Plan:
Planned Procedures: Permanent Pacemaker, vitals every 8 hours, limit activity to bed rest diet should be
lower in sodium measure input and output of liquid, continue monitoring electrolytes and consult cardiology
for echo-cardiogram and possible pace maker.
References:
STUDENT SIGNATURE: