for those of who who're interested, he's a swiss immigrant who had a PE.. presented a week ago with sudden worsening dyspnea causing him to collapse despite rest while cutting grass on his farm on a history of an acute sharp pain at his left calf radiating up his inner thigh made worse with movement/restricted walking (? Homan's sign +) 6 weeks ago.
his GP told him it was prolly mm cramps, prescribed panadol and also scheduled him for excision of his melanoma on anterior left chest. Pain self-resolved 5 days later without him taking panadol. had urinary incontinence with collapse. no headaches, vertigo, fevers, rigors, associated chest pain. described his SOB as "couldn't get air in" ~ no cough, sputum, history of respiratory disease. no asthma, pneumonia, TB, blahblahblah. also had severe flank pain radiating to lower back with gross abdo distention at time of presentation last week. had abdo CT done, showed enlarged kidneys. told it was just fatty deposits. had a vein stripped 30 yrs ago in switzerland for similar type of pain. no other risk factors for DVT ~ no recent surgery requiring immobilization, no recent long distance travel, no family history, no history of stroke/MI, definitely not on the pill or HRT... exercise tolerance normal - spends time working on farm, walks dogs at least once a day for a few kms. No orthopnea, sleeps well, flat on 1 pillow. no personal history of heart disease. GI system ok other than colonoscopy and treatment of hemarroids 5 years ago that were causing bleeding. other systems unremarkable. no other previous medical history or known medical problems ~ no HT, diabetes, hyperlipidemia, prostate cancer etc.
the dude's a chronic alchoholic (ohhhh... i have about half a liter of red wine and a few schooners of beer. about 3 or 4 of those. yes, i have that every day.. i mix the wine with iced tea you know..) and ex-cigar smoker of 10 years who averaged 1 cigar a week. (how do u estimate pack years for cigars...) not on any regular medication, no ADR/allergies.
Family history: mother had CABG, diabetes. died in 2000 at 83, father is 90, alive and well.. brother is 63, no known med probs for latter 2.. he's 57, lives on farm with wife, both immigrated here in '78, no kids. was a chef in swizterland, owned hotelier. worked as caterer, driver at building sites transporting steel/concrete, turned farmer 10 years ago.
P/E: vitals normal.regularly irregular pulse pattern tho. ruddy complexion, very ambulant (searched the friggin hospital for him!), hooked up to heparin drip. vesicular breath sounds, even/normal chest expansion, hyperresonant @ right lung apex, dull to percuss @ left lower base with decreased breath sounds and vocal resonance (???). could also be that vocal resonance was increased at right lower base tho.. anyway, HSDNM, normal JVP. abdo distended, numerous petechiae, couldn't elicit shifting dullness, umbilicus pointing slightly inferiorly. hyperresonant @ right flanks. tender in lower 2 quadrants with light palpation. couldn't palpate liver... or anything else really. kidneys not ballotable. palmar erythema, no clubbing, small mm wasting, asterixis, peripheral cyanosis, couldn't find pedal pulses, cold white toes, edema up to mid-calf on left leg. no central cyanosis, xanthelasma, horner's, scleral icterus, anemia.
he's most likely had a DVT 6 weeks ago that got dislodged and gave him the PE last week on top of hepatic disease prolly due to his chronic alcoholism. already on panadol and heparin. started on warfarin yesterday. one would assume he's already had a CXR and/or CT, ABG, FBC, glucose, lipid levels, UEC, LFT, INR, D-dimers, V/Q scan or pulmonary angiography done. might do an ECG as a just-in case.. might show arrythmias. *shrug* stick some TEDS on the guy, encourage early ambulation (he's got that down pat..). stop heparin in ~5 days' time, measure INR and maintain between 2.0 - 3.0. as for the gastro problems.. refer to gastroenterologist! *grin* hey, that's the beauty of being able to say "sorry, my subspecialty this term was respiratory.. i don't know enough about gastro and being a lowly 4th year med student who doesn't even qualify as the bottom-most layer of scum in the hospital hierarchy, i'd seek a more expert opinion."
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