JUMBO – HOTDOG Samantha V. Cosalan

MD 080032

HISTORY

IDENTIFYING DATA• F.D., 47 year old• Male• Single• Filipino, Roman Catholic• Lives in Mandaluyong• Works as an Area Manager of Jollibee• Source of data from the patient and his girlfriend, fair

reliability• Admitted November 12, 2011• History and Physical Exam done November 15, 2011

CHIEF COMPLAINT

• Fever• Dizziness

HISTORY OF PRESENT ILLNESS

• On the day of admission, patient developed persistent dizziness described as “drunk-like”, not aggravated by head movement, and was relieved by rest • Patient also had fever (Tmax 39.8 C), intermittent dry

cough of 1 week duration and generalized body weakness• No associated nausea, vomiting, ear symptoms• Self medicated with Alaxan 500mg and Biogesic, minimal

relief

• Patient was brought to the TMC ER by his girlfriend where the initial impression was SVI vs URTI• Patient was advised admission for further work-up due to

persistence of symptoms despite treatment

• Patient was admitted at Room 1424• (+) Discoloration or dorsal aspect of both lower extremities• Right leg: red, swollen, tender• Persistence of fever, T = 38.8 C

• Diagnosis at the floors was Cellulitis, right lower extremity

• On the patient’s 3rd hospital day, desaturations were noted and he was moved to the ICU• Girlfriend reports that the patient snores excessively at

night at that is tired most of the day • Patient denies DOB, chest tightness, lethargy

PAST MEDICAL HISTORY

• Asthma, no maintenance medications, last attack >30years ago• Dengue (2005)• Patient took no medications (steroids) in the past• No HTN, Diabetes, TB, Liver/Heart/Kidney Disease• No maintenance medications• No previous surgeries• No history of wading in flooded waters• No history of recent travel• No known allergies to food or medications• Patient has regular yearly check-ups with doctors

FAMILY HISTORYPatient’s mother – HTN, StrokeYounger brother – HTN Patient’s father – DM

No TB, Asthma, Kidney/heart/liver disease

PERSONAL/SOCIAL• Works as an Area Manager of Jollibee• Lives with his girlfriend in Mandaluyong• Diet is “well balanced”

• Pork, chicken, rice, vegetables• Girlfriend however claims that he eats very large servings• Patient has always been a heavy eater and has been overweight

since childhood

• He is not allowed to do strenous exercises (basketball) since his doctor claims that his knees won’t hold his weight

• Recently started walking 3x/week for 30-45 min and occasionally plays badminton

• Employer is monitoring his weight loss as part of Performance Management

• Does not smoke, drink or take any illicit drugs

ROS• General: No weight changes• Skin: No lumps, sores, itching, dryness, color change,

changes in hair or nails• HEENT: No history of head trauma, lightheadedness, blurring

of vision, eye tenderness, double vision, flashing lights. No sore throat, hoarseness, dry mouth

• Neck: No lumps, tenderness, stiffness• Respiratory: No hemoptysis, dyspnea, wheezing• Cardiovascular: No chest pain or discomfort, palpitations,

dyspnea, orthopnea, edema• Gastrointestinal: No difficulty swallowing, heartburn, changes

in appetite, rectal bleeding, abdominal pain, jaundice

• Urinary: No frequency, nocturia, urgency, burning or painful urination, incontinence, hesitancy, dribbling

• Genital: No hernias, discharge, testicular pain or masses• Peripheral Vascular: No claudication, leg cramps, varicose

veins• Musculoskeletal: No muscle or joint pains, stiffness,

arthritis, gout• Neurologic: No fainting spells, blackouts, paralysis,

numbing or loss of sensation, tingling, tremors, involuntary movements

• Hematologic: No easy bruising or bleeding• Endocrine: No heat or cold intolerance, excessive

sweating, excessive thirst or hunger, polyuria

PHYSICAL EXAMINATION

GENERAL SURVEY

• Patient is alert, awake, not in respiratory distress

• Patient is lying in bed, comfortable, is of heavy build, well groomed wearing a hospital gown

• Patient appears agitated and is uncooperative during the interview

VITAL SIGNS

Patient’s Value InterpretationTemperature 39.1 C AfebrileHeart Rate 84 Normal

Respiratory Rate 19 NormalBlood Pressure 100/70 mmHg Normal

Pain 6/10 Moderate

ANTHROPOMETRICS

• BMI = 42 (Obese Class III)

HEENT

• Hair is of average texture, no lesions on the scalp

• Pink oral mucosa, septum midline, good dentition, no sinus tenderness

• No TPC, CLAD• Supple neck, trachea midline, no neck

enlargement/masses

CARDIOPULMONARY

• Equal chest expansion, lungs resonant• Clear breath sounds with no

rhochi/rales/wheezes• Adynamic precordium, normal heart

rate with regular rhythm, good S1 and S2 no murmurs, no heaves or thrills, apex beat at 5th ICS left MCL

ABDOMEN

• Flabby, soft, normoactive bowel sounds• Nontender, no surgical scars, no

organomegaly• Liver span 7cm in right midclavicular

line • Spleen and kidneys not palpated• Traube’s space intact

EXTREMITIES• No atrophy and weakness

on all extremities• Right lower extremity

• Red, swollen, tender, warm to touch

• (+) Hyperpigmentation on both lower extremities

• Full and equal pulses

NERVOUS SYSTEM

• Patient is alert and agitated, GCS 15• Right handed• Thought is coherent and oriented to person,

place and time • Cranial nerves intact• Good muscle bulk and tone, 5/5 strength,

reflexes +2

SALIENT FEATURES• Fever and dizziness• Morbidly obese, Class III (BMI 42)• Hyperpigmentation on both lower

extremities (cyanosis)• Cellulitis, right lower extremity • Patient is a heavy eater• (+) Snoring at night• Episodes of desaturation at the floors

WORKING IMPRESSION

Cellulitis on the R lower extremityt/c Obesity Hypoventilation Syndrome

Obesity

CellulitisMetabolic Syndrome

OSAObesity

Hypoventilation Syndrome

Desaturation

DIFFERENTIALSRULE IN RULE OUT

Metabolic Syndrome

Obese Class II Diagnostics

OSA Obese Class IISnoring

Tired during the day

Polysomnography

OBESITY HYPOVENTILATION SYNDROME

• Based on Charle’s Dickens’ book The Posthumous Papers of the Pickwick Club

• Character Joe• “wonderfully fat boy,

standing upright with his eyes closed”

• Poor breathing leads to lower oxygen and higher carbon dioxide levels in the blood

• Main symptoms• Sleepiness, depression and headache• Chronic hypoxia (shortness of breath, easy fatigability)

• Physical Exam• Bluish color in lips, fingers, toes or skin • Right sided heart failure (swollen legs or feet, SOB)

• Treatment• BiPAP, tracheostomy, oxygen• Weight loss