Rheumatology Clinic Case Study

PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.

HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42-year-old gentleman from Bangladesh who presents with chest tightness, shortness of breath, and tachycardia. Dr. J.K. McClain of cardiology is evaluating his heart condition. The patient has had the recent onset of hemoptysis. He was treated for tuberculosis in Bangladesh 15

A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

PAST MEDICAL/SURGICAL HISTORY: As above. SOCIAL HISTORY: Status post heavy smoking, 50+-pack-year history. He quit 10 years ago. Status post alcohol abuse, quit 3 or 4 years ago. He lives by himself and no longer drives but has 2 daughters here in Miami who take him where he needs to go. FAMILY HISTORY: Patient’s wife died 14 years ago of COPD due to lifelong smoking. Brother has diabetes mellitus. Unremarkable family history otherwise. REVIEW OF SYSTEMS: No fever, no nausea, no vomiting. Patient has incontinence of bowel. No shortness of breath, no chest pain, no palpitations. PHYSICAL EXAMINATION: Well-developed, well-nourished white male who is alert and oriented x3. Wears bilateral hearing aids. Afebrile with blood pressure 130/70. NECK: No carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: S1, S2 normal. No murmur. No S3 or S4. ABDOMEN: Soft, nontender. No arterial bruits. No masses, no organomegaly. EXTREMITIES: No edema. No pulses present in the lower extremities. The right great toe is absent. The left great toe shows a 2 x 1 cm deep ulcer with redness around the toe with pus extruding. PLAN 1. Get consult with Dr. Beth Brian, Infectious Disease. 2. Follow up with Dr. Hirsch, Orthopedics. (Continued)

Pulse rate is at 72. The blood pressure was 140 / 95,which is suggestive of high blood pressure and related to his medical history. No heart murmur was noted, and no other abnormalities were noted.

PHYSICAL EXAMINATION: HEENT: Tympanic membranes and external auditory canals are within normal limits. Throat is clear with no gingival lesions. He is ______________. No obvious proliferate retinopoathy. NECK: No carotid bruit. No thyroid enlargement. LUNGS: Clear to auscultation. HEART: No S3, S4 or murmurs. ABDOMEN: Soft with no organomegaly. Normal bowel sounds. FEET: Good dorsalis and posterior tibial pulses bilaterally. Left foot has no abrasions, lesions, sores or ulcers. Right foot shows obvious deformity from previous break. He has an area located between his second and third metatarsal head that has clearly been an abscess that has broken through. He also has an obvious foot ulcer located over the instep of his right foot, full thickness. There is tracking to the broken foot, to which the ulcer area is connected and there is a question of osteomyelitis in this area.

The general health of the patient is currently being compromised due to present illness mentioned above, but is stable. L.H. reports his usual health to be, “normal and not too crazy like this”. Patient has some fatigue noted while conducting daily activities; No recent weight change, fever or sweat. The skin noted to some discoloration on upper right side of back. There is no pruritus, rash or lesions present. Bruises noted bilateral on arms. Patient reported taking baby aspirin as daily medication. His hair is greying and thinning with no hair loss.

Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 - S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2

Mr Brown is a 76 year old male, which presented to the emergency department via ambulance with thoracic back pain, which commenced two days prior to the presentation. The triage assessment stated the patient is alert, orientated, distressed, chest clear and equal, neurovascular intact with equal strength in all extremities and good strong regular pulses. The nil injury stated patient said he ‘just woke up with it’. The patient’s observation displayed a temperature of 36.9°C, blood pressure of 169/105, pulse rate of 99 beats per minute, respiratory rate of 20 breaths per minute, Glasgow coma score of 15, and a blood glucose level of 5.4. Mr Brown’s has a past medical history of atrial fibrillation, asthma, emphysema, hypertension, chronic back pain, lumbar fusion (L1), total

Mr. Johnson is a 28 y/o African American man, presents with an 8 month history of heart burn in the epigastric region. Pt. reports “I have heart burn after each meal and it’s painful to swallow at times” Pt. reports a productive cough. The pt. throat is reddened. Pt states the pain worsens while lying down and rate pain 8 out of 10. Pt takes 3 antacid a day. Pt. has a history of hypertension and Asthma. Pt. reports sour taste in back of throat and regurgitation.

Patient is a 45 yo male; 5’7”, 221 lbs who entered the emergency room at 6:30 am on 9/7/14 with severe chest pain (onset at 6:00 am) radiating to his arm, L arm numbness and nausea and vomiting. Past medical history reported by wife includes peptic ulcer, tobacco use (1-2ppd for 27 years), elevated blood pressure (controlled by lopressor). Wife did not know of any family history but reports patient’s father is deceased, died at 42 in his sleep. Mother alive and with high blood pressure.

At today's visit, he is found lying in bed in his room at palm gardens SNF. He is alert and oriented. He reports chronic SOB, resulting from his COPD. He is wearing his oxygen. He complains of chronic dull low back pain that does not radiate. His pain is a 4/10 in severity, When he reposition, it aggravates his pain. He reports that his pain regimen includes MS ER 15 mg po q 12 hours and Percocet

Obese male, 259 pounds. For his height, he is a minimum of 60 pounds overweight. Blood pressure 129/75, pulse 70, respirations 18. Hemoglobin A1c this quarter was 6.3%. I think that is up just 0.2 from what it was last quarter. Also, has a history of hepatitis C. I did a new FIB-4 score on him and it has not changed it is still 1.5. To the nodules that he has appears to be a small ganglion cyst. They appear to be in the tendon region of the extensor of the second digit and the same with the bottom of the foot, at this time very small, does not seem to be all that tender with palpation.