VA Morning Report 8/8/14

VA Morning Report 8/8/14

VA Morning Report 8/8/14 Mark Gold Intern My Family My Hometown Palestine

Greatest Accomplishment Adrian Peterson Personal Maturity Case Presentation Patient

is a 60 yr old male veteran presenting to Temple VA from OSH s/p 2 syncopal episodes Patient has recorded drugseeking behavior and previous admissions for syncope with no positive findings despite extensive work-up

PMH: HTN, HLD, OA Chronic Hip, Knee, Lower Back Pain PSH: R femur and back surgery FH:

Father - MI 60s Maternal GF - Colon CA Uncle - Lung CA SH: T 20 pack year history EtOH Quit 10 years ago D - None

Meds: NORCO 325/10MG Q6H PRN for pain ATORVASTATIN CALCIUM TAB 10MG PO qHS for cholesterol DILTIAZEM 360MG PO DAILY for BP GABAPENTIN CAP 600MG PO TID for pain NAPROXEN TAB 500MG PO BID/FOOD PRN for pain NICOTINE 14MG/24 HRS PATCH PRN for tobacco use PAROXETINE TAB 20MG PO qHS

PRAZOSIN 1MG PO HS for nightmares TRAMADOL 50MG PO TID PRN for pain TRAZODONE TAB 100MG PO qHS PRN for sleep Allergies: NKDA ROS Negative except for findings in HPI

Syncope Work-Up Troponins Negative x3 Tele and EKG

Sinus tachycardia TTE EF 55-60%; No wall motion abnormalities (Sept., 2013) Orthostatic Vitals

Negative EEG No epileptiform activity Chronic Pain Radiographs Knee no acute abnormality

Back no acute abnormality Patient given home pain regimen and referred to pain clinic Day of Discharge Nurse,

please tell the doctor My Eye is Red and Really Hurts! Red Eye History

and Physical Differential Diagnosis Common Presentations Distinguish Emergent from Benign Problem History for red eye

1) Vision affected? *If acute change, ophtho referral 2) Foreign body sensation? *Objective unable to spontaneously open eye or keep it open (corneal damage) *Subjective feels sandy or gritty (allergies, conjunctivitis, dry eyes) 3) Photophobia? *If yes, ophtho referral (corneal or iris etiology)

*Consider migraine HA History for red eye 4) Trauma? *Blunt vs sharp? 5) Contact lenses? *Increased risk of infection 6) Discharge other than tears? *Eyes crusted shut in the morning

Physical Exam for red eye 1) Visual Acuity * Read, follow fingers, distance 2) Penlight Exam *Pupils - PERRL *Anterior segment Redness, Foreign Body, Blood or White Cells in Chamber ***Eyes Vital Signs Vision, Pupils,

Pressure Normal Eye Normal Eye Acute Angle Closure Glaucoma

Acute Angle Closure Glaucoma Acute Angle Closure Glaucoma Acute Angle Closure Glaucoma Physical

Exam Findings: Severe HA +/- malaise Patient in obvious distress N/V with high pressures Fixed pupil in mid-dilation (4-5mm) IOP often >45 (normal 8-22)

One eye may feel like a rock Ciliary flush with no discharge ***Urgent Ophtho Referral*** Hyphema Hyphema

Hypopion Hyphema/Hypopion Physical Exam Findings: RBCs/WBCs in anterior chamber

Hyphema associated with significant blunt or penetrating trauma to globe Hypopion associated with sightthreatening infection ***Urgent Ophtho Referral*** Bacterial Keratitis

Bacterial Keratitis Inflammation of the cornea Physical Exam Findings: Corneal Opacity or Infiltrate Conjunctivitis with a large infiltrate Foreign Body Sensation

Higher incidence with overnight contact wearers Photophobia Mucopurulent/Watery Discharge (+/-) ***Urgent Ophtho Referral*** Corneal Abrasion vs Corneal Ulcer

Corneal abrasion CANNOT see without fluorescein Should heal with time Corneal ulcer

VISIBLE before fluorescein Ophtho emergency Closer to the pupil, the worse it is Iritis/Anterior Uveitis Iritis/Anterior Uveitis

Iritis/Anterior Uveitis Physical Exam Findings: Ciliary flush without discharge Photophobia without foreign body sensation Common

etiologies: HLA B27 Ankylosing Spondylitis, UC, Chrons Disease, Reactive Arthritis (Reiters Syndrome) Sarcoidosis Syphillis, Toxoplasma, Toxocara, Lyme Disease, TB ***Ophtho Consult***

Subconjunctival Hemmorhage Subconjunctival Hemmorhage Physical Exam Findings:

Usually asymptomatic Bruise under the conjunctiva (change colors like a bruise) Generally well-demarcated area of extravasated blood beneath surface of eye Amount of blood may seem to increase on day 2 due to redistribution

***Reassurance this will resolve with time*** (Unless in setting of trauma evaluate for open globe) Subconjunctival Hemmorhage Conjunctivitis

Conjunctivitis Inflammation of the outermost layer of the eye and inner layer of the eyelid Physical Exam Findings: Mucupurulent/Watery (Stringy) Discharge Itchy Eye +/- viral symptoms

Precede or follow a cold x 10 days Pre-auricular lymphadenopathy (Viral etiology) Often associated with exposure to sick contacts with similar symptoms ***Cool compresses, artifical tears, begin appropriate therapy and encourage copious hand washing***

Blepharitis Blepharitis Inflammation of eyelash follicles along base of eyelid Physical Exam Findings: Eyes crusted shut in the am

Eyes not nearly as red or purulent as conjuncitivitis Tend to be in older patients ***Warm Compresses +/- ABX ointment*** Back to our patient No

visual defects PERRL Pressure within normal limits No objective foreign body sensation Final Result Pain

resolved with artificial tears and patient was discharged in stable condition Conclusion When you encounter a red eye

History Physical Vision, Pupils, Pressure Rule Out Dangerous Conditions Acute Angle Closure Glaucoma Hyphema/Hypopion Bacterial Keratitis/Corneal Ulcer

Iritis/Anterior Uveitis When In Doubt, Call LUKE POTTS Resources 1)

2) 3) 4) Berson, Frank, et al. Basic Ophthalmology for Medical Students and Primary Care Residents. San Fransisco, CA. 1993; 57-75 Jacobs, Deborah. Evaluation of the

Red Eye. UpToDate 2014. Leibowitz HM. The Red Eye. NEJM 2000; 343-345. Brett McKnight 2nd year S&W ophthalmology resident Questions? Thank

time! you all so much for your

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