Case Study on 68 year old man
68 year old man (Eddie) presents to ED via QAS from fall at home. Eddie was found on the floor by paramedics after pressing his vita-call button. His speech was slurred on scene and his breath smelt acidic. On arrival, Eddie’s GCS was 14 and was verbally abusive to paramedics. Eddie has a contusion to the back of his head and cut marks to his L) arm for which he states he ‘accidentally put his hand through his glass window’. Eddie lives alone in an aged care retirement community.
Personal History: Eddie is a retired boiler maker with 4 children all over the age of 40. Eddie admits to being generally healthly ‘apart from the occasional flu’. Eddie states that he has been a little more tired these days but seems to think that is because he no longer goes to art class in the village and has slowed down on his daily walk because his left knee is ‘starting to cause him grief’. Eddie admits to indulging in a few drinks lately because his friends don’t talk to him anymore and his children are too busy.
Family History: Father died of bowel obstruction leading to septicaemia at 85. Mother medication history of diabetes, 23 surgeries throughout her life-artificial arteries in upper extremities and legs due to atherosclerosis.
Medical History: History of angina, hypertension, GORD, appendectomy at age 13. Eddie admits to recently being started on Tramadol for his knee pain which is currently under investigation by his local GP.
He is on a range of medications:
Anginine prn, Metoprolol 50mg BD, aspirin 100mg OD, Atorvastatin 40mg Nocte, Esomeprazole 40 mg BD, mylanta PO, Pulmicort Turbuhaler 400mcg BD, Ventolin 2 puffs prn, panadeine forte 2 tabs prn, Zoloft 50mg mane. Lasix 40mg BD. Blackmores Glucosamine tablets 1500mg OD.
VITAL SIGNS:
• Respiratory Rate: 22
• Blood Pressure: 168/97
• Temperature: 36.5
• Heart Rate: 107
• SP 02: 95% on RA
Systems Review
NEUROLOGICAL: GCS is 14/15 with pupils equal and reactive to light (PEARL). Patient is confused at times and verbally abusive. Contusion to back of his head.
RESPIRATORY Inspection: The patient displays comfortable breathing, slight cough. There are no abnormal thoracic landmarks or scars.
Palpation: Chest expansion is symmetrical.
Percussion: Lung fields clear, resonant sounds.
Auscultation: There is air entry into all lung fields. Fine crackles can be auscultated on inspiration.
CARDIOVASCULAR: Inspection: The patient is centrally pink.
Palpation: Peripheral pulses are palpable at +3. Calves are soft and non-tender.
Auscultation: Heart sounds of S1 & S2 are heard. Irregular heart beat noted.
An ECG shows atrial fibrillation and a portable chest radiograph showed clear lung fields.
An arterial blood gas shows a pH 7.30, Pa02 78 mm Hg, PCO2 58 mm Hg, HCO3 27 mEq/L, and Lactate 2.1 mm Hg. Spirometry results include FEV1/FVC of 75%.
Electrolytes Na 140, K 4.3, CL 100, HCO3 22, GLU 8.1, Urea 4.4, Creat 0.06
ABDOMINAL Inspection: The patient is sitting up, nil distress. Skin is pink and warm. Abdomen not distended. No bruising, striae, surgical scares or lesions. The abdominal wall is moving symmetrically with respirations. Bowels not opened regularly
Auscultation: Bowel sounds are present.
Percussion: Abdomen is resonant to percuss.
Palpitation: slight tenderness lower abdomen