Dishwasher Case Study
SUBJECTIVE
He presents for evaluation of episodes of feeling like he is going to pass out. He had his first episode last April or May when he was working in the kitchen loading the dishwasher. He describes it as a feeling that his "whole body got tingly. He initially wondered if it was related to the fact that he had been sleeping during the day and only eating one meal every 24 hours. More recently, however, he has been having more frequent episodes. The most recent one was in the evening of 11/14. He was preparing to go in the shower when he started feeling somewhat dizzy. While he was in the shower, his vision started to go dark. His body felt tingly, his legs felt weak. He dropped his towel, bent down to grab it and it slipped through his hands three times before he could grasp it. He sat down and gradually began to feel better. He wonders if these episodes could be due to his medications for a couple reasons: There were three days when he did go to the pill window to take his nortriptyline and his symptoms were …show more content…
better, when he started taking it again symptoms resumed. Also, on further questioning, he had two episodes of migraine headache last week and used his Imitrex both times, which he has not used for a while. He is also on Prozac for depression. Again, with his most recent episodes, he has only been eating one meal a day.
OBJECTIVE
Weight 174 pounds, blood pressure 128/88, pulse 95, temperature 97.5, O2 sat 99%.
Neurologic exam: Pupils are equally round and reactive to light. Extraocular movements are full. There is normal strength for the _____ in facial musculature, normal palate rise and tongue movement. Strength in the trapezius in the upper and lower extremities is normal and symmetrical bilaterally. Deep tendon reflexes are 2+ biceps, triceps, brachioradialis, and patellar. I cannot really elicit an Achilles reflex on either side. Neuro exam: Romberg test is negative. Gait is normal. He does have a mild fine tremor of the hands bilaterally, which he states is relatively new. Lungs are clear to auscultation throughout. Heart: S1, S2 normal. No murmur, rubs, or gallops. Auscultation in the neck reveals a definite carotid bruit on the left, which on my exam does not appear to be a referred murmur. Reviewed his lab. He has any blood work since
2015.
ASSESSMENT
1. Near syncopal episodes-etiology may include medication effect as he has three drugs that effect neurotransmitter and he may be sensitive, particularly given his observation that symptoms are less when he is off nortriptyline. Glucose dysregulation or low blood glucose when not eating could be considered. Orthostatic hypotension may also cause these symptoms, but he did not have orthostatic symptoms today. 2. Carotid bruit. This may be contributing to his near syncope and needs workup, although I note that he is only 53 years old and has no other history of atherosclerotic coronary vascular disease.
PLAN
1. We will put in a request to have a carotid echo. Will also check complete metabolic profile, thyroid function, and hemoglobin A1c. 2. Will decrease his nortriptyline to 25 mg daily. He opted for this rather than outright discontinuing it. 3. Followup in two weeks for lab results and symptoms recheck. Patient understands the plan and agrees.
He presents for evaluation of episodes of feeling like he is going to pass out. He had his first episode last April or May when he was working in the kitchen loading the dishwasher. He describes it as a feeling that his "whole body got tingly. He initially wondered if it was related to the fact that he had been sleeping during the day and only eating one meal every 24 hours. More recently, however, he has been having more frequent episodes. The most recent one was in the evening of 11/14. He was preparing to go in the shower when he started feeling somewhat dizzy. While he was in the shower, his vision started to go dark. His body felt tingly, his legs felt weak. He dropped his towel, bent down to grab it and it slipped through his hands three times before he could grasp it. He sat down and gradually began to feel better. He wonders if these episodes could be due to his medications for a couple reasons: There were three days when he did go to the pill window to take his nortriptyline and his symptoms were …show more content…
better, when he started taking it again symptoms resumed. Also, on further questioning, he had two episodes of migraine headache last week and used his Imitrex both times, which he has not used for a while. He is also on Prozac for depression. Again, with his most recent episodes, he has only been eating one meal a day.
OBJECTIVE
Weight 174 pounds, blood pressure 128/88, pulse 95, temperature 97.5, O2 sat 99%.
Neurologic exam: Pupils are equally round and reactive to light. Extraocular movements are full. There is normal strength for the _____ in facial musculature, normal palate rise and tongue movement. Strength in the trapezius in the upper and lower extremities is normal and symmetrical bilaterally. Deep tendon reflexes are 2+ biceps, triceps, brachioradialis, and patellar. I cannot really elicit an Achilles reflex on either side. Neuro exam: Romberg test is negative. Gait is normal. He does have a mild fine tremor of the hands bilaterally, which he states is relatively new. Lungs are clear to auscultation throughout. Heart: S1, S2 normal. No murmur, rubs, or gallops. Auscultation in the neck reveals a definite carotid bruit on the left, which on my exam does not appear to be a referred murmur. Reviewed his lab. He has any blood work since
2015.
ASSESSMENT
1. Near syncopal episodes-etiology may include medication effect as he has three drugs that effect neurotransmitter and he may be sensitive, particularly given his observation that symptoms are less when he is off nortriptyline. Glucose dysregulation or low blood glucose when not eating could be considered. Orthostatic hypotension may also cause these symptoms, but he did not have orthostatic symptoms today. 2. Carotid bruit. This may be contributing to his near syncope and needs workup, although I note that he is only 53 years old and has no other history of atherosclerotic coronary vascular disease.
PLAN
1. We will put in a request to have a carotid echo. Will also check complete metabolic profile, thyroid function, and hemoglobin A1c. 2. Will decrease his nortriptyline to 25 mg daily. He opted for this rather than outright discontinuing it. 3. Followup in two weeks for lab results and symptoms recheck. Patient understands the plan and agrees.