H&P

10Jun2020 1100

49 y/o male with PMH of prediabetes, and HTN presents to family medicine clinic for f/u after visiting the ER. He states his wife woke up to him having a seizure “violently shaking” and she called 911. The ambulance transported him to St. Johns medical hospital and started him on seizure medication. He states he does not remember the incident but had 1 seizure previously in 2018, but did not seek medical attention. He continues to mention that he has not seen a neurologist nor did the ER perform any imaging of the brain. He is requesting a duty status to return to work.

He mentions he is having right shoulder pain x 3-4 months and states that the pain is getting worse. He cannot lift the right arm without the help of the left hand and states the pain is localized to the anterior and superior regions of the shoulder. He has occasional numbness/tingling down his right arm to his finger tips and complains that his grip strength is not what is used to be. He has trouble shaving, combing his hair and getting dressed in the morning. Denies headaches, blurry vision, diplopia, auras, hearing loss, tinnitus, vertigo, syncope, lightheadedness or trauma. Denies contact with covid pts.

PMH: prediabetes since 2016.

HTN since 2010

Surgical History: Tonsillectomy 1975. No complications. No issues with anesthesia.

ALL: NKDA

Shellfishàanaphylaxis
Meds: Phenytoin 300mg capsule PO qd

Colace 100mg capsule PO qd

Ergocalciferol 50000 units capsule PO once weekly

Ferrous Sulfate 325mg tab PO qd

Aspirin 81mg tab qd

 

Family History: Mother alive.

Father alive

Social history: pt had 15 pack year hx. ETOH  “social drinking.” Works for NYCHA and is requesting clearance to work.

ROS:

Constitutional: Denies weight loss, fatigue, night sweats

Head: LOC (seizure), confusion. denies trauma, HA, changes in vision

Neurologic: See HPI. denies syncope, focal weakness, numbness or tingling.

Eyes: Admits to itching and tearing, denies visual acuity issues.

ENT: denies tinnitus, hearing loss, vertigo, stuffiness, sore throat or neck pain.

Cardiac: Denies palpitations, murmurs, chest pain.

Pulmonary: Denies cough, hemoptysis, fibrosis.

Hematology: Denies bruising, petechiae, or purpura.

Skin: Denies edema, bruises or excoriations.

GI: Denies N/V/D, jaundice, constipation.

GU: Denies urgency, dysuria, inguinal hernias, polyuria or nocturia.

Musculoskeletal: Admits to joint pain, instability and weakness. Denies trauma.

Psychiatric: denies stress, anxiety, depression or mood changes.

Physical Exam

Vitals: 136/88 pulse: 64 Resp: 18 SpO2: 98% RA. Temp 98.1

BMI 32.0% (height 70” weight 223lbs)

WNWD male NAD A&OxIII. Good hygiene, rambling affect and unable to maintain conversation. Appears stated age.

Head: Normocephalic, no scars or lesions or trauma.

Eyes: Symmetrical: Iris brown. Noted bulging eyes and erythema over sclera and conjuntivae. No ptosis, icterus. EOMI without nystagmus. PERRLA. Fundoscopic exam: Vessels sharp, no cotton-wool spots or papilledema. Visual acuity deferred.

Ears: Symmetrical: No TTP over tragus, lobe or helix. AU-EAC unobstructed. TMs pearly gray, no injection or bulging TM noted.

Nose: Septum midline. Patent airway. No rhinorrhea noted. Inferior turbinates observed. No hematoma, discharge or foreign body.

Mouth/Throat: Teeth intact and no evidence of loose teeth or dentures. Tongue, uvula midline. Tonsils present grade 2. Uvula midline. No PND.

Neck: Supple, no palpable goiter or TTP.

Lymph nodes: No palpable lymphadenopathy. No TTP.

Lungs: No adventitious lung sounds.

Heart: RRR without gallops, skips or murmurs. Audible S1 S2.

Abdomen: Bowel sounds heard throughout, no general or rebound tenderness.

Gentourinary: examination deferred. DRE deferred.

Skin: Noted clubbing of fingers. No edema, ecchymosis or rashes.

Musculoskeletal: TTP over AC joint and bicipital groove and along the scapular spine of right shoulder. Severe limited ROM of right shoulder with flexion, extension, abduction and adduction. Muscle strength 3/5 on right. DTRs intact. Apleys scratch test positive and apprehension test unable to preform.

Mental status: Appropriate memory, with adequate repetition, no aphasia or dysarthria.

Neurological exam: Cranial nerves: II-XII grossly intact. Noted decrease dexterity with cerebellar function and rapid alternating movements. Romberg positive.

Assessment/Plan

62 y/o male w/ PMH of HTN presents to medical with signs of tonic-clonic seizures and with suspected adhesive capsulitis. Instructed patient to return home and see neurology as soon as possible. Educated patient on importance of proceeding to local emergency room if seizure symptoms present and instructed patient not to drive. RTC after initial appointment with neurology.

Ddx:

Seizure

Syncope

Adhesive capsulitits

Labral tear

Rotator cuff tear

Problem list:

1. Seizure NOS
   1. Neruology referral given. Report to ER if seizure occurs
   2. Continue phenytoin 300mg PO qd.
2. Conjunctival hyperemia, bilateral
   1. Start Claritin tablet 10mg, PO qd.
   2. Ophthalmology referral given
3. Adhesive capsulitis
   1. Orthopedic referral given.
4. Elevated blood pressure reading; without diagnosis of HTN.

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Typhon

Family Medicine Typhon

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Peer-Reviewed Article

Pathogenesis_and_management_of_diabetic_foot.6

I chose this article for a number of reasons. Chiefly, because a lot of the patients I helped manage suffered from diabetes and in that right feet checks were an important part of quality healthcare. The article explained the occurrence of diabetic ulcers and the number of surgeries performed annually. In addition, the article focused on the pathophysiology of the diabetic ulcers and how the elevated glucose wreaks havoc in the body. The article specifically mentioned tools that the clinician can use to better assess issues with the feet secondary to diabetes. This includes the use of a tuning fork and the importance of testing sensation along all aspects of the foot. The article reiterated the stages of ulcers and also provided important complications that are associated with diabetic foot ulcers, specifically osteomyelitis. The clinical management focused on a long list of important treatments for a diabetic patient with a foot ulcer. However, the most effective and important therapy for a patient with a foot ulcer is surgical debridement. Without this crucial step the other treatment modalities are drastically inferior and do not provide adequate care for the patient.

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Site Evaluation

My site evaluation was quite productive. I had a thorough meeting with my site evaluator and he went over in detail the importance of imaging a patient with new onset seizure. The necessary steps that it takes to provide quality healthcare for a patient with a seizure involves stroke protocol and that was something that I did not think about while managing this patient. Overall, the meeting was a success.

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Summary

This rotation was heart-felt and rewarding. The location of the clinic I was assigned to was focused on under-served populations and patients with minimal medication education. I spent a great deal of my time educating my patients on the importance of low salt diets, low fat diets and the importance of counting carbohydrates in my diabetic patients. The patients who came to the clinic were often not acutely sick, but chronically sick with life altering illness ranging from congestive heart failure to renal failure to cancer. I know I spent more time with my patients, but in doing so I built a rapport with these people.

One of the more difficult parts of this clinical rotation was the long list of medications the patients were taking. The list could be as detailed as 20-25 medications and all of them chronic. Medication use ranged from gout, to hypertension, to diabetes to anxiety. All of which had both their generic names and sometimes their brand names listed. This was a steep learning curve and I would often have to look up the medication and its use if it was something I didn’t recognize. At times patients would be on 3 or 4 different medications to treat the same disease (hypertension) and for many patients insurance was not covering all of their prescriptions. I found the work at family medicine rotation rewarding and important, especially with the under-served population and especially at this time of crisis (COVID-19, race disparities).