This patient was admitted for shortness of breath, fever and chills. He has a history of cystic fibrosis, with secondary diabetes.…
A 32-year-old female presented to the Emergency Department because of myalgia, muscle weakness, and severe abdominal pain often associated with nausea. Similar episodes had occurred since she was 18. She also complained of previous bouts of depression. She stated that these symptoms would occasionally disappear, but always returned especially around the onset of her menstrual period. Prior to her current episode, she had been prescribed antibiotics for a urinary tract infection. Routine blood and urine laboratory results were normal as well as a CT scan of her abdomen and pelvis. Two days after admission, the physician was notified by the clinical laboratory that her urine sample had turned a deep red color after sitting…
HISTORY AND PHYSICAL EXAMINATION OR EMERGANCY DEPARTMENT TREATMENT RECORD Patient Name : Benjamin Engelhart Patient ID : 112592 Date of Birth : 10/05/1958 Age : 46 Sex : Male Date of Admission : 11/14/2014 Emergency Room Physician : Alex McClure, MD…
Patient X is a 52-year-old man who lives in Bowen Hills, Brisbane. He is an automotive repair man. However, he has recently lost his job and has stayed idle for one year. Recently, he was playing basketball with his eldest son and suddenly developed a substernal chest pressure. When he thought it was just a typical ‘heartburn’, he continued playing. After another 20 minutes, he had an intolerable sharp, nagging chest pain. His left arm became numb. His son verbalised that he looked pale and was sweating a lot. His son called the paramedics which accordingly arrived after 30 minutes and he was brought to Royal Brisbane and Women’s Hospital.…
HISTORY OF PRESENT ILLNESS: This 46-year old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis presents to the emergency room after having had 3 days of abdominal pain. It initially started 3 days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o earlier around 6am, but he now denies having an appetite. Patient had a very small bowel movement early this morning that was not normal for him. He has not passed gas this morning. He’s voiding well. He denies fevers, chills, or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy.…
The patient was brought to my office by her daughter on the day of admission. She appeared dehydrated and weakened. There were periumbilical ecchymosis and…
In addition, it can also be accompanied with nausea, vomiting, fever, leukocytosis, and abdominal muscle guarding (Huether & McCance, 2012). In the case of client M.E., when she first was admitted by the emergency department she displayed abdominal pain and rebound tenderness in the right upper abdominal quadrant. Additionally, she was experiencing some nausea; however, her abdomen was non-distended, and assessment findings revealed her having a body temperature within defined limits. In addition, her laboratory findings indicated a high white blood cell count, which is a common finding associated finding with cholecystitis due to the pathophysiological process explained above. Though, in order to confirm client M.E.’s medical diagnosis of cholecystitis, and abdominal ultrasound was ordered. Results of the abdominal ultrasound illustrated a distended gallbladder with gallstones measuring up to 1.7 cm, which in fact confirmed the diagnosis of…
Patient is 63 year old African American/Black male. Patient was brought in emergency department. The patient wife said he has been complaining of unusual stomach pains. According to the patients wife before bringing him in to the emergency room he was vomiting blood.…
His vital signs are as follows: BP 172/100, heart rate 92, and a temp of 102.2 F. The results from the lab results are as followed: RBC 3.1 million, WBC 22,000, K+ 5.4 mEq/L, Ca 6.8 mg/dL, phosphate is 4.3 mEq/L, urea is 37 mg/dL, creatinine 2.0 mg/dL, albumin is 2.9 mg/dL, and pH is 7.29 after these abnormal labs a Chemistry Panel was drawn. Labe results of the Chemistry Panel are as followed: Protein 1.7 gm/24 hours, GFR of less than 30 ml/minute, and urine sediment showed presence of gram negative bacilli, presence of white blood cells, presence of red blood cells, and granular and waxy casts.…
History: Martha Wilmington, a 74-year-old woman with a history of rheumatic fever while in her twenties, presented to her physician with complaints of increasing shortness of breath ("dyspnea") upon exertion. She also noted that the typical swelling she's had in her ankles for years has started to get worse over the past two months, making it especially difficult to get her shoes on toward the end of the day. In the past week, she's had a decreased appetite, some nausea and vomiting, and tenderness in the right upper quadrant of the abdomen.…
He woke up during his sleep with a severe 8/10 pain locating to the lower quadrants of the abdomen. Having been for a buffet dinner the night before he initially blamed this on food poisoning, but he became feverish and dehydrated so seeked further help. He had not recently travelled and no other contacts at the meal were ill. He had opened his bowels more often than usual in the past 24 hours, but no diarrhoea or blood with the stools.…
T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his…
PHYSICAL EXAMINATION: Physical exam reveals a well-developed, well-nourished 35 year old white female in a moderate amount of distress at the time of the examination. VITAL SIGNS: Show temperature 97 degrees; pulse 53; respirations 22; blood pressure 108/60. HEENT: Unremarkable except for poor dentation. Neck: Soft and supple. CHEST: Lungs are clear in all ???. HEART: Regular rate and rhythm. ABDOMEN: Soft but positive tenderness of her lower abdominal…
PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished male who appears to be in moderate distress with pain and swelling in the upper left arm. VITAL SIGNS: Blood pressure 140/90, temperature 98.3 degrees Fahrenheit, pulse 97, respiration 18.HEENT: Head normal, no lesions. Eyes, arcus senilis, both eyes. Ears, impacted cerumen, left ear. Nose, clear. Mouth, dentures fit well, no lesions. NECK: Normal range of motion in all directs. INTEGUMENTARY: Psoriatic lesion, right thigh, approximately 1 mL in diameter. CHEST: Clear breath sounds bilaterally. No rales or rhonchi noted. HEART: Normal sinus rhythm. There is a holosystolic murmur. No friction rubs noted. ABDOMEN: Normal bowl sounds. Liver, kidneys, and spleen are normal to palpitation. GENITALIA: Tests normally descended bilaterally. RECTAL: Prostate 2+ and benign. EXTREMITIES: Pain and swelling noted above…
REVIEW OF SYSTEMS: Patient complains of a lower abdominal pain for the past week that apparently got much worst last night and by this morning was intolerable. She is also having some nausea and vomiting. Denies hematemesis, hematokesa, and melena. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies…