Welcome to Grand Rounds Volume II, No 28

Welcome to Grand Rounds. This is the brainchild of Nick Genes from Blogborymi who decided to organize a weekly compilation of medical blogs back in 2004, and put in motion what Grand Rounds has become today.

I have decided to organize this into a very familiar form for most of us in the health care professionals: The History and Physical Exam:

CC (Chief Complaint): I have a "winky" problem".

HPI (History of Present Illness):

Mr. G. Rounds is a 52 yo man who presented to the Emergency Room a few days ago after a MVA (motor vehicle accident). His teenage daughter was the driver who fell asleep at the wheel when they hit a tree. The patient was the restrained passenger, and though the car did not have an airbag, he suffered just minor injuries because of his beer belly. Both he and his daughter were immediately stablilized by an excellent EMT team, and when he was efficiently evaluated in the ER, he was found to have a phimosis, and there was some difficulty with catheter placement. The phimosis has been there for several years, though it has started to bother him just recently.

He suffered a broken ankle and sprained wrist from the MVA, and was admitted for observation and tried to be a helpful inpatient, especially with the nursing staff who empathized with him as a patient.

He did not have health insurance for a couple of years when he was unemployed and became depressed and he had difficulty obtaining medical care. Because of the high costs of prescriptions, he did try some alternative remedies such as chinese herbal medicine, but this did not control his diabetes.

Recently, he's had a difficult time staying with a PCP (primary care physician), since he didn't like the attitude of some doctors who treated him just like a customer. He has been very happy with his most recent internist Dr. Patel, though some of her other patients complained about her strong foreign accent. However, he has just found out that she left the medical field altogether because of the bureaucracy and hassle involved with billing . He is now actively seeking another PCP since he does not want to fall prey to the Frankenstein syndrome.

He is a well-informed patient, and is very involved in his own healthcare issues. He does a lot of research through the internet and peruses frequently through medical blogs.

Despite the diabetes that has been part of his life since childhood, he has managed to find zen like acceptance, though there have been times of frustration as well. Sometimes he finds a good outlet in simply letting it all out.


PMH (Past Medical History):

CAD (Coronary Artery Disease)
DM (Diabetes Mellitus) which had required ICU admission twice for DKA (diabetic ketoacidosis).
Hypertension
Osteoarthritis


Medications:
Chondroitin and glucosamine
Insulin

Habits:

He is a vegeterian, but he is starting to slowly introduce meat into his diet.
He does not smoke.
He drinks a glass of wine on weekends.
He enjoys two cups of Dunkin Donut coffee per day.
He does not use any recreational drugs, especially since he has seen tragic consequences from this.


FH (Family History):

Both parents are alive. His mother is African American and has heart failure from CAD (Coronary Artery Disease). Her diagnosis was delayed because of atypical symptoms, but new and improved cardiac imaging helped clinch the diagnosis. She had a CABG (Coronary artery bypass graft) and despite prayers, she has done quite well. Innovative stem cell therapy may soon be on the horizon for her.

His father was recently diagnosed with a malignant brain tumor and is deciding between Hospice Care vs. Home Health.



SH (Social History):

He is married with three teenage daughters.
He is a methodist minister and he has travelled extensively in Asia and Africa as a missionary, and is quite familiar with zoonoses.


PE (Physical Exam):

Temp 37, BP 175/85, P 76, RR 20

Gen: Alert and oriented pleasant man in NAD (no acute distress). He is in a wheelchair because of his injured extremities.

Mood and Affect: normal

Chest: CTA

Cor: RRR

Abd: soft, no masses, no abdominal tenderness.
No organomegaly

Genitalia: bilaterally descended testes, non tender
Uncircumcised penis. The foreskin cannot be retracted past his glans because of a severe phimosis.

DRE (digital Rectal exam): 40gm prostate, smooth, non tender, non nodular.


A /P (Assessment and Plan):

1. Hypertension: Mr. Rounds states that his blood pressure at home has been much lower, and thinks he may be suffering from "white coat syndrome". We will recheck it at his next visit.

2: Diabetes: under excellent control.

3. Phimosis: it is symptomatic, and I have recommended a circumcision.

(I had to end it on a urological note!!!)


Next week's Grand Rounds will be hosted by Anxiety Addiction and Depression Treatment. You can submit new posts to jtschnaars@treatmentonline.com
Phew, that's a mouthful.