History And PhysicalDiane Morris

Patient is a 60 year old white female who presented to the Emergency Room with complaints of dizziness and “just not feeling right” for a couple of days. Patient states that she was in the car with her male friend they were at a stop light went to turn her vision went blank she became dizzy, and couldn’t hear. Male friend pulled over to the side of the road so she could get her barings. After patient was able to open up her eyes she thought her blood sugar was low ate some candy that she had in her purse and continued to the family function they were going to checking her blood sugar when she got there and it was in the 120’s. Patient stated that she continued to feel “funny” and called her Doctor on Monday for evaluation. Patient was scheduled to have blood work done and outpatient CT for the next day. Patient was still concerned that she was not feeling well on Monday evening, so she went to the Emergency Room for evaluation. Patient was evaluated for possible stroke versus TIA. In the emergency room patient had a CT scan, CXR, EKG and blood work done. CT scan was negative and showed no acute changes, lab values were all within normal limits and CXR showed nothing abnormal.

History of Present Illness

Surgical History: s/p Cholecystectomy 1984 s/p Appendectomy 1978 s/p Myxoma Left Atrium 1990 s/p Left Ear “something removed” 1993

Past Medical History

Medical History: A-Fib Type 2 Diabetes Hypothyroidism Vertigo Sleep Apnea, uses CPAP Anxiety High Cholesterol

Past Medical History

Patient is divorced lives alone but does have a male friend. Patient does all her own ADL’s, finances and still continues to drive. Has one daughter that lives in the area. Patient denies any use of alcohol, tobacco or illicit drug use. Pt is retired after being a secretary for thirty for years. Pt is a full code.

Social History

Both parents are living. Father has a history of heart disease, cardiac stents, pacemaker, prostate cancer, CABG, and esophagitis and now has to eat pureed food. Mother has a history of HTN, Type One Diabetes, and memory loss with dementia/Alzheimer.

Family History

Codeine: nausea and vomiting Iodine and Seafood: rash and hives Serzone: hallucinations Celexa: hallucinations Albuterol: increased heart rate

Allergies

Synthroid 188mcg daily-hypothyroidism Potassium 20 mEq BID Xanax 0.5mg BID-anxiety Coumadin 2mg daily-blood thinner Amiodarone 200mg daily-A-fib Lipitor 10mg-high cholesterol Vitamin D 2000iu daily Zaroxolyn 5mg daily-water pill used for

treatment in patients with heart or liver disease Amaryl 1mg daily-Type Two Diabetes Lasix 40mg daily-fluid retention

Medications

Glimepride 2mg daily-Type Two Diabetes Metolazone 5mg daily-water pill used to

treat HTN Tylenol prn Nasonex prn

Medications

Constitutional: Alert, oriented, skin warm dry and pink, patient is able to answer all questions appropriately, states she has not been feeling well for the last couple of days.

Eyes: PERRLA, denies any changes in vision, only vision change was when episode happened on the car and vision went blank for a second

ENT: Denies any nasal drainage or any changes with hearing, does not wear hearing aids, using Nasonex PRN

Skin/Breast: Denies any rashes, minimal bruising due to medication, no open wounds at time of admission, breast exam not performed

Review of Systems

Cardiovascular: Denies any SOB, CP or chest pressure, irregular heart rhythm (A-fib) which is normal for patient

Pulmonary: Denies any SOB, cough or sputum production

Endocrine: no changes in appetite, pt is taking Amaryl and Glimperide as prescribed

Gastrointestinal: Denies any problems with bowel

Genitourinary: Denies any increase or pain with urination

Review of Systems

Musculoskeletal: Denies any changes in strength, joint tenderness or swelling, no recent falls or trauma

Neurological: Able to answer all questions appropriately, no headache, short and long term memory intact, c/o dizziness with head movement

Psychology: Denies any changes in mood, patient takes Xanax as needed for anxiety

Heme/Lymph: Bruising from medications, no history of DVT or PE, patient is taking Synthroid as prescribed

Review of Systems

Vitals: Temp 36.6 Pulse 87 RR 16 BP 131/51 O2 Sat 98% RA

Physical Exam

General: Patient does not appear in any distress, sitting up in bed, eating breakfast

Eyes: PERRLA, EOM intact, no redness or drainage, able to open and close eyes with no difficulties

ENT: No nasal drainage, no difficulty with swallowing, smile equal no drooping, denies any problems with hearing at this time, states at time of incident everything went dark and couldn’t hear

Neck: No redness, swelling or any palpable masses, thyroid not enlarged

Physical Exam

Lymph Nodes: No lymphadenopathy Cardiovascular: Irregular rhythm (A-fib), RR, no

carotid bruits, no JVD Lungs: Clear to auscultation, no wheezing or use of

accessory muscles Skin: No rashes, skin is warm dry and pink, minimal

bruising due to medication Breast: deferred Psychiatry: denies feeling anxious, just wants to

know if something is wrong Abdomen: Bowel sounds present in all four

quadrants, no pain or tenderness with palpation

Physical Exam

Genitourinary: Genital exam not performed, does not pertain to patients complaint

Rectal: Rectal exam not performed, does not pertain to patients complaint, patient denies any problems with bowels or any blood in stools

Extremities: No edema, clubbing, cap refill <3 seconds, pulses equal bilaterally 3+

Musculoskeletal: Full ROM all extremities, no edema, no deformities

Neurological: A & O x 3, no slurred speech, no neuro deficits, CN 2-12 intact, moves all extremities with no difficulties

Physical Exam

WBC 6.13 RBC 4.01 Hgb 12.0 Hct 31.6 BUN 23 (result a little high, Lasix can

increase level, Diabetic) Creat 1.2 (normal range but on the high

end) Na 138 K 4.3

Pertinent Diagnostic Tests

Cl 99 BiCarb 24 Caclium 9.0 CPK 72 Trop <0.015 HgA1c 7.3 Chol 135 Tri 62 HDL 70 LDL 53 VLDL 12 TSH 2.5

Pertinent Diagnostic Tests

PT 3-5 25, 3-6 26.1, 3-7 26.1 INR 3-5 2.4, 3-6 2.5, 3-7 2.5 UA was neg, no protein in urine

Pertinent Diagnostic Tests

EKG: A-Fib, patient has a history of A-fib, no acute changes since last EKG that is on file

CXR: no infiltrates, no effusions, no acute changes since last x-ray was obtained

CT: no acute changes MRI: Negative for any acute bleeding or clots, no

tumors Echo with bubble study: normal study, air bubbles

followed the normal pathway of the heart Carotid Doppler: normal blood flow, no evidence

of carotid stenosis

Pertinent Diagnostic Tests

TIA vs. Stroke Vertigo/Dizziness Stress Reaction

Differential Diagnosis

Vertigo/Dizziness: sensation of motion when there is no motion or an exaggerated sense of motion in response to a given bodily movement, hearing loss is the key to diagnosis for vertigo

Peripheral vertigo: onset of sudden, often associated with tinnitus and hearing loss, horizontal nystagmus may be present

Central vertigo: onset is gradual, no associated auditory symptoms

All tests and lab results came back within normal limits. Patient states that she was feeling better but still had dizziness with head movement.

Impression (final diagnosis)

MRI Echo with bubble study Carotid Doppler Vestibular Rehab PT/INR Lipid Panel

Plan

Patient was admitted to the telemetry floor for continuous monitoring. Orthostatic blood pressures were obtained and showed no difference in laying, sitting or standing. More lab work was obtained for testing lipid levels, HgA1C, and PT/INR daily while admitted to the hospital. More extensive study was ordered: MRI, Carotid Doppler study, and Echo with bubble study. Discharge instructions include following up with PCP in a couple of days, Cardiology in one month and Vestibular Rehab the next day. Instructions also include having repeat lab work done to follow PT/INR. Patient also educated about changing positions slowly, to sit at the end of the chair prior to standing up and sitting on edge of bed before standing. Patient states that her daughter will be able to stay with her for a few days to help take her around to different appointments.

Plan

After evaluating the patient I talked with my preceptor explained her story and what I thought her diagnosis was and what testing should be done. My preceptor agreed with my diagnosis and ordered what testing I suggested, plus some that he suggested: echo with bubble study and carotid doppler. The main things that I would do differently were to order the other testing and take a bigger look at the picture to think of everything that could be the cause of her dizziness. I did not know though what the echo with bubble study was, so I need to learn about the different types of testing there is to order.

Reflection of Care