Case Presentation (Full Version)

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Dr.Wagner -> Case Presentation (June 25, 2006 12:46:00 PM)

A 17 year old female is brought to you by her concerned parents stating "She has been 'off balance' lately...well for about 1-2 weeks."

On initial impression she appears disinterested, but in good health.

What do you want to know or do?

drbuddy -> Re: Case Presentation (June 25, 2006 1:20:00 PM)

First off, I may pull the parents aside and ask them to go have a cup of coffee while I review her history and chief complaint. If they ask why, I'd tell them that teenagers tend to be more open and honest without the parental units present.

I would want her to describe this "off balance" feeling and when and how often it happens. Also, I would ask if she has noticed any other symptoms, either related or unrelated. Also check her health history for anything significant.

Depending on her answers and her history, I would want to know more about her eating habits, if she's sexually active, if her menstrual cycle has been regular, if she has started taking any meds, vitamins, herbs, etc., and if she has been experimenting with any social drugs such as marijuana, alcohol, "E", etc.

I'll pause there and see if that gives us any clues...

Sebastian Asselbergs -> Re: Case Presentation (June 27, 2006 6:36:00 AM)

Buddy, I second that notion, but I would ask the parents first to define more precisely what they mean by "off balance". Do they mean true "balance", or is it like a behavioural issue? Then I would have the 17 year old privately descibe her perceptions....

Dr.Wagner -> Re: Case Presentation (June 27, 2006 8:24:00 AM)

The parents state "well, she is know off balance"
Past surgical history: colposcopy, appendectomy
Past Medical history: HPV "abnormal cells", tobacco use, epilepsy, trichomonas

When you talk to the 17 year old in the room she rolls her eyes and is less than helpful...depending on what you ask.

USAPT -> Re: Case Presentation (June 27, 2006 9:54:00 AM)

The "abnormal cells", is this cancer related?

Have the parents consulted with their family MD or was the PT the first stop?

drbuddy -> Re: Case Presentation (June 27, 2006 11:42:00 AM)

So, she has no answer to the questions, or do we just have to ask the right thing?

Was there a follow up to the abnormal cells? Could be cancerous or an STD.

If she doesn't answer any of those questions, I guess we'll have to rely on a physical exam and tests.

I would perform vitals, neuro, heart, lungs, abdominal, and gynecological exams. Depending on what those exams tell us, we may need to order some tests.

USAPT -> Re: Case Presentation (June 27, 2006 11:53:00 AM)

The current Med hx reveals hx of STDs already. And the gyno tests have been done as well based on info given from Dr. Wagner.

what were the results of the colposcopy?

Sebastian Asselbergs -> Re: Case Presentation (June 28, 2006 6:54:00 AM)

Has her nutritional intake changed recently? What does she smoke? What meds do the parents have that she can get her hands on? Bladder function? BMs? Sleep? When does the dizziness occur? Time of day? Position? ...etc..etc...
The rolling of the eyes is "normal" for 17 year olds, but could also indicate when you've hit on a close-to-home question. What did you ask to make her roll her eyes?

Shill -> Re: Case Presentation (June 28, 2006 11:49:00 AM)

Yes, but is the rolling of the eyes a nystagmus?
Im kidding.

drbuddy -> Re: Case Presentation (June 28, 2006 1:25:00 PM)

"And the gyno tests have been done as well based on info given from Dr. Wagner."

I dont see any gyno exam results done on this visit...

Randy Dixon -> Re: Case Presentation (June 28, 2006 4:02:00 PM)

If it's too "medical" I wouldn't have any idea. I would just give her some gross balance tests, check for nystagmus and get an urinalysis to check for drug use.

History of epilepsy would ring some bells for me. Wouldn't dizziness be a symptom of that? It may account for some of the attitude, the part not explained by 17 y.o. Also she is likely on medications, so we need to check for changes or new meds.

USAPT -> Re: Case Presentation (June 28, 2006 4:26:00 PM)

the colposcopy and pelvis exam /pap to detect HPV and trichomonas.

What other gyno tests would you want to know about? I'm curious b/c I have no idea myself. I had to look up what the colposcopy was:).

USAPT -> Re: Case Presentation (June 28, 2006 4:37:00 PM)

Is she having complications / exacerbations from her epilepsy? Any frontal lobe damange that may be changing her behavior/personality?

drbuddy -> Re: Case Presentation (June 28, 2006 5:55:00 PM)

I am thinking those were done in the past and not necessarily since this "dizziness" started. So, I would want to do a current exam. Mostly just palpation and inspection at this point to look for abnormal masses, tenderness, bleeding, etc.

drbuddy -> Re: Case Presentation (June 28, 2006 8:02:00 PM)

I was looking for a more current exam, palpating for any abnormal masses and check for abnormal bleeding. I think those other tests were done in the past and not necessarily since the onset of her symptoms.

Dr.Wagner -> Re: Case Presentation (June 28, 2006 9:57:00 PM)

The family state..."she had some 'abnormal cells' on her last pap, something about HPV."

When Buddy states "I think we need to do a pelvic" the family look at each other and state "what does this have to do with her dizziness"
(do you still wish to procede with the pelvic?)

As for medications: daily vitamin, BCPs, albuterol prn, dilantin

Social: she smokes "maybe a pack a week", and "weed every once and a while"

Prior to the Physical you want anything else? Tell me WHAT you want on the physical exam.

drbuddy -> Re: Case Presentation (June 28, 2006 10:10:00 PM)

Ok, I will rephrase. I would ask when she had her last pelvic exam. If none recently, then I would explain that it is important to have it checked to rule out problems such as abnormal bleeding, which can lead to blood loss and cause the 'dizziness'.

Prior to the physical exam, I would like answers to some of the questions I asked earlier. Also, ask about her dilantin. I see that higher doses can cause dizziness.

When you ask WHAT I want to do on the physical exam, what do you mean? Perform the inspection, palpation, percussion, auscultation, etc. like you would normally do and see what we come up with.

Dr.Wagner -> Re: Case Presentation (June 28, 2006 10:42:00 PM)

How about this...
You decide to ask her about vaginal bleeding she states "I'm not on my period and I'm not bleeding at all...not even spotting"

(to procede or not)

You read the pill bottle of dilantin it states "100mg po tid"

As for the physical exam...
I just wanted to know what YOU wanted to know...trying to make this fun and educational.

drbuddy -> Re: Case Presentation (June 28, 2006 11:12:00 PM)

I see...

Ok, let's start simple. Is that a high dose for dilantin? Was is changed recently? Could they provide any other answers to some of the questions asked above? Specifically, did they offer any more info about the dizziness?

USAPT -> Re: Case Presentation (June 29, 2006 10:27:00 AM)

I too would like to know about the dilantin w/ respects to the dosage and/or side effects with other meds which would increase affects of the dilantin.

I gotcha ya...more recent tests and all..I agree

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