Hancock, Mills, et al. present: Santa Rosa Family Medicine Residency, September 17, 2012
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1 Hancock, Mills, et al. present: Santa Rosa Family Medicine Residency, September 17, 2012
2 Ms. L
3 39F with developmental delay, also: Primary germ cell brain tumor s/p resection at age 17 with resulting panhypopituatarism Poorly controlled DM2 (HbA1c = 10) Gout Recurrent UTIs Lives at home with 71y single mother who works as a janitor at local hospital, attends Becoming Independent daily PHP Insurance
4 DDAVP inhaled Prednisone Levothyroxine Insulin Januvia Metformin Estrogen Provera Allopurinol Simvastatin Vitamin D, Calcium Aspirin Intermittent antibiotics
5 Me Santa Rosa Endocrinologist UCSF Endocrinologist Oncologist Diabetes clinic Others
6 1/13/12: OV: 1 month of worsening ataxia, new use of walker, dysarthria. Stroke? MRI, echo, ASA ordered. 1/26/12: Provider goes on vacation for 2 weeks. 1/27/12: MRI report: ventriculomegaly out of proportion to atrophy, consider NPH. Covering provider saves report for return of PCP 2/13/12: Provider returns from vacation to Medicine serv
7 2/16/12: Study finally acted upon and urgent referral to Neurosurgery made. Pts mother called & informed 2/17/12: TE: Mom states that she called the neurosurgery to schedule appt at but they informed her that there was no referral. please call back 2/25/12: Pt seen in office: unable to get through to UCSF at phone number provided by clinic. Calls made to UCSF to assist with scheduling appt while in office. In-house neuro clinic appt made to help with diagnosis while waiting for UCSF to see.
8 3/29/12: OV: Pt seen by Dr. Lim in Neuro clinic. LP done after significant urging of precepting neurologist. Pt has still not been seen at UCSF. Pt improved in days following removal of 30 cc of CSF. 4/5/12: OV: 39 F here to f/u Neuro clinic visit. Pt seen by UCSF neurosurg, based on history provided by family uncertain whether ataxia was acute or long standing so did not evaluate for VP shunt -requested neurology c/s. Called Neurosurgeon & discussed case w/ NP, who stated she would review with attending.
9 4/10/12: OV: Pt seen again. Still no info from UCSF. Titrating endocrine meds. UCSF called again. 4/13/12: TE:Stacy from UCSF Neuro called to inform Dr. Hancock that surgery is actually not needed. Dr. Lim saw Elva on 03/29/2012, and according to his note "unclear if VP would be helpful." UCSF called again and case discussed with Stacy again. Subsequent visit notes faxed for documentation. 4/15/12: Patient scheduled for f/u visit at UCSF (per phone conversation with mother), but no notes ever received.
10 5/11/12: OV: NPH undergoing further w/u,? tumor board review, and intensive PT (2 days/week) at Healdburg hosp w/ plan to review all imaging and PT outcomes on 6/4 at UCSF and make a decision about whether to proceed w/ VP shunt 5/11/12: VP shunt placement 5/25/12: Doc: Dear Christine Hancock, MD, At the time of admission to UCSF Medical Center or UCSF Benioff Children s Hospital, the patient noted above identified you as the referring or primary care physician. Please let us know if this is not correct.
11 5/25/12: OV: POD 14. Doing better -continued improvements in walking, speech. 5/30/12: staples out 6/12/12: Endocrine visit: labs ordered by Dr. Fish, R3, return just before graduation Na = 154. Pt instructed by phone to increase dose of DDAVP (taking tabs because covered by PHP). 6/17/12: Missed return visit 6/18/12: PCP on elective away, but still checking jellies daily.
12 6/22/12: TE: Called pts mother to check in -pt having worsening dysphagia (eating only soft foods) and ataxia (using walker a lot). Concerning sx given recent VP shunt placement/nph. Paged pts neurosurgeon x2 without callback, Finally able to reach on call Nsurg. Will send pt to ER for non-con head CT and other w/u to r/o worsening NPH/shunt malfxn, discussed w/ ER MD on call, provided UCSF contact info. PCP out of town over weekend, gave cell to ER MD. Pt d/ced home after negative workup 6/24/12: pt admitted to ICU with BP of 70, lactate of 3.5, Na of 170, K 2.9. Managed by ICU and hospitalist service.
13 6/26/12: PCP called mother to find out what happened, states Elva almost died yesterday, she is in the ICU 6/26/12: PCP called intensivist to discuss case, who as not aware pt had resident PCP or what her PMH included. Pt transferred to resident service and gradually improved to point of discharge.
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