本日の新患さんは、morbit obesityな患者さん。
私にとっては、普段（アメリカ人にとってはobeseでもなんでもない患者さん）でも歩行試験を一人でやる勇気が無い（倒れても支えられない！！）ような患者さんばっかりのなか、morbitが付くような肥満の患者さんというのは、さらにすごいです＞＿＜
筋トーヌス見るのとか、腱反射とか、ホント重くて一苦労。。
せっかく1ヶ月神経内科を回ったので、神経所見についてでも。 と思ったのですが、その前に、まずは私のadmittion noteでも。まだまだ未熟なので、突っ込みどころ満載だとは思いますが。
アメリカのカルテの雰囲気は伝わりますかね？略称だらけで、ホント最初は意味不明でした。
カルテは個人情報だから、本物は当然書けないので、ここに書くとなると自分で作らなくてはいけなくて、現病歴まで全て作るの大変だから現病歴は飛ばします（笑）
本物のadmittion note, progress note見たい、という稀有な方がいれば、連絡下さい。紙カルテバージョンも、電子カルテバージョンも持ってます。
MS admittion note Mari Hayata
CC: Lt arm weakness and pain
HPI: The pt is a ××yo right handed Asian woman, who had ...以下省略。
ROS:
Waterly diarrhea: nl color, after every meal since gastric bypass
Fever: around 100F since 4/15(Wed), afebrile today
Lost 25lbs since operation.
Denies HA, visual problem, runny nose, sore throat, change in taste, neck pain or stiffness, chest pain, palpitation, SOB, cough, abdominal pain,change in urination (frequency or amount), pain in armpit, joint pain or swelling.
PMH:
1. Severe morbid obesity (class 3 BMI=42)
2. Diabetes mellitus (HbA1c of 7.3 on greater than 100 units of insulin/day)
3. Obstructive sleep apnea requiring CPAP
4. HTN
5. GERD
6. acanthosis nigricans
7. polycystic ovarian syndrome
8. amenorrhea
9. s/p laparoscopic cholecystectomy(2003), requiring subsequent ERCP and sphincterotomy
Meds: (私が薬苦手＆アメリカで薬の名前が分からない、ということで何の為とか、何か、ということも記載しるだけです＞＿＜)
for Lt arm pain
Oxycodone-Acetaminophen 5-10ml PO Q3H (NSAIDs)
Gabapentin 250mg PO tid (Anti-convulsants)
Ranitidine 150mg PO bid (H2 blocker)
Pantoprazole 40mg IV Q24H (PPI)
Losartan Potassium 150mg PO daily (ARB)
Simvastatin 40mg PO daily (HMG-CoA reductase inhibitor)
Insulin SC
Lorazepam 0.5mg PO Q4H (Benzodiazepine)
Duloxetine 20mg PO bid (SNRI anti depressant)
Multivitamins 1tab PO Q4H
All:
NKFDA
SHx:
No tabacco, EtOH or drug.
Lives at home with her two children (age 4 and 1). Housewife.
FHx:
DM in father (onset of 50yo) and grandfather.
Colon cancer in maternal grandmother.
No HTN or CAD.
Exam:
T 97.0, BP 144/94, HR 98, RR 18, O2sat 97%(RA)
Gen: Lying in bed, NAD, morbid obesity (102.7kg)
Skin: acanthosis of both axilla
HEENT: NC/AT, conjunctivae pink, sclerae non icteric, MMM
Neck: no tenderness to palpation, nl ROM, supple, no carotid or vertebral ruit, not able to palpate thyroid
CV: RRR, nl S1S2, no S3S4, no m/g/r
Lung: CTAB
Abd: open sergical scars in periumbilical region, +BS, soft, nontender, distended, no bruits, not able to check hepatosplenomegaly
Ext: nl turgor, no c/c/e, good peripheralpulses at radial and dorsalis pedis
Neurologic examination:
MS:（主訴によりけりで、MSはどれだけでも細かくとります。かつ、日本と違う点が多々あり、一番最初に戸惑った診察項目の1つ）
Gen: awake but lethargic and would intermittently fall asleep, snoring while asleep, nl affect
Orientation: oriented to person, place, date, and situation
Attention: +MOYbw. Follows simple/complex commands.
Speech/Lang: fluent w/o paraphasic errors; conprehension, repetition, naming and reading intact
Memory: registers 3/3 and recalls 3/3 at 5 min
Calculations: 7quarters=$1.75
L/R confusion: touches Lt ear with Rt hand
CN:
I: not tested
II, III: VFF to confrontation, PERRL 4mm to 2mm
III, IV, VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT and pinprick
VII: facial strength intact/symmetrical
VIII: hears finger rub b/l
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii 5/5 b/l
XII: tongue protrudes midline, no dysarthria
Motor: nl bulk and tone; no tremor, asterixis or myoclonus. Lt pronator drift.
Delt Bi Tri WE FE Grip IO IP Quad Hamst DF EHL PF
C5 C6 C7 C6 C7 C8/T1 T1 L2 L3 L4-S1 L4 L5 S1/S2
L 5- 3 4 4+ 4+ 5- 4 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5
Other muscles in LUE were
Supraspinatus 5-, infraspinatus 4+, brachioradialis 2, opponent pollicis 4, abductor pollicis brevis 3+
Strength in RUE were 5 throughout.
Reflex: no clonus
Bi Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0 tr 2 0 0 mute
R 2 2 2 0 0 mute
Sensation: Decreased to LT, pinprick and temp on Lt in roughly C6-C7 region. Vibration and proprioception intact.
Hypersthenia and allodynia in forarm and dorsum of hands, with tenderness of ulnar nerve around elbow.
Coordination: finger-nose-finger skillful w/o dysmetria or discomposition on Rt (not able to exam Lt due to her weakness), heel-to-shin skillful, RAMs nl.
Gait: no initiation hesitation, narrowbased, steady
Romberg: not tested
Labs:(4/20)
8.2 \ 11.1/ 407
33.3 MCV=87
Diff: Neurs 79.3, Lymphs 14.9, Monos 5.1, Eos 0.5, Baso 0.2
138 103 6 /
----------- 128
3.5 26 0.5 AnGap=13, Ca 8.8, P 3.5, Mg 1.9
UA(4/19): RBC 10, WBC 4, Bac few, Ketone 10, Urobiln 4
Stool(4/20): negative for C.difficile toxin A&B
Pre albumin :PND
Blood, stool, urine, swab culture: PND
（A/P）
ここからが一番大事な部分。
アメリカではS/Oまではとれて当たり前なので、A/Pが出来ないと出来たことになりません。
residentにも、presentationをする時にA/Pがattendingをimpressする部分なんだから、ここを頑張れ！と言われます。
でも、私にはまだまだ難しくて、私の鑑別疾患・A/Pは「正しいけど、後1歩。だから？その先は？」と突っ込まれます＞＿＜
The pt is a ××yo F with DM,obesity, HTN, …以下略。患者さんを1文で要約します。
On exam, muscle strength was 4 throughout, in Lt, especially weak for 3 in Bi. Her sensation to Lt, pinprick, and temp was decreased toughly in C6-C7 region.
DDx:
- brachial plexoplathy
She has both motor and sensory deficits in broad root levels w/ hypersthenia and allodynia, which strongly suggest peripheral neuropathy, especially plexopathy.
Her motor weakness is form C6-C(, especially in Bi(C6) and BR(C7), which corresponds with her sensory deficit roughly in C6-C7.
- 次の鑑別疾患。以下略。
Further plan:
- EMG: next week to assess the nerve injury
- Pain control (as Gabapentin increased)
以下、この意味不明な略語の嵐のカルテの解説＆神経学的所見の取り方の説明をざっと書いてみました＾－＾
No comments:
Post a Comment