SUBJECTIVE Mr. Hamilton was readmitted to MCCRC on 03/02 and seen on 03/05/2018. Mr. Hamilton had been here after a motor vehicle accident, leaving here with fractured ribs, pneumonitis, fractured sternal, and a complicated right acetabular hip fracture. He recuperated and was able to return home on analgesics. He was on amiodarone, Lasix, metformin, and glimepiride for his diabetes. He did not check his blood sugar, although I had advised him to do so.…
On 2/11/2016, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in gray pants, pink shirt and black jacket with a multicolor knit hat. She was cooperative, friendly and happy. CM observed that the client face cheek was a little swollen. CM inquires the reason client face is swollen. Client reported is because she didn’t have medication for a few days.…
0830 Focus assessment. Alert and oriented x 4 and follow commands. VS T 96.7, P 76, R 18, BP 129/67, O2 Sat 94 RA. Pt denied pain at this time. Pain 0 on a scale of 0 to 10 Heart sounds normal, regular and even. S1 and S2 auscultated. Lung sounds normal and clear in all lobes. Non labored and non-shallow. Bowel sounds active and present in all four quadrants. ABD soft, non-tender to palpate. Pt denied ABD pain and constipation. Pt stated last bowel movement two days ago (2/23). Call light with in her reach, all necessary items close by pt………………………..L.Gotora PNS2/WATC…
The patient is 67-year-old gentleman who presents to the ER because of recurrent falls. He has a past medical history of the left quadriceps rupture several months ago, repaired at Morristown Medical Center and he was in rehabilitation at the Atrium at Wayne he was discharged from the Atrium rehabilitation center on the 8th. He presented to several EDs on the 9th and also was discharged from and including St. Joseph's emergency room he is complaining of his right leg was collapsing on walk he represented to St. Joe's ED on the 10th and at that time because of a history it was determined that he required acute inpatient admission. His medical history is significant for diabetes mellitus, hypertension, and dyslipidemia. He seen by the cardiologist…
Patient is a 61-year-old white male admitted through the ER with on December 10 with recurrent right pneumothoraxes. Patient is known to have COPD with emphysema and has multiple admissions for problems concerning this. At the time of initial evaluation, a small caliber chest tube was inserted in the anterior axillary line, which improved the patient’s respiratory distress but did not completely resolve the pneumothorax. I was called to the ICU to place a second small caliber chest tube in the posterior axillary line below this. This further improved the patient’s pulmonary status with his saturation improving from 76& to 89%. Since admission he has felt better but complained of pain at the chest tube insertion site. He has continued to leak out through the pleur-evac under water seal, and beginning yesterday he developed subcutaneous emphysema, which has gotten progressively worse. Earlier today he began having increased respiratory difficulty again, with his saturation dropping to approximately 80 % despite oxygen per nasal cannula. Chest x-ray today showed a worsening of the right lower lobe loculated pneumothorax, and on examination today he is not only leaking air through the pleur-evac system but also around the two chest tubes.…
This patient was admitted for shortness of breath, fever and chills. He has a history of cystic fibrosis, with secondary diabetes.…
HOSPITAL COURSE: This 57-year-old Cuban female was admitted from my office for treatment of severe stomatitis and mild volume depletion secondary to poor fluid and food intake. Initially, the possibility of erythema multiforme-like picture was raised because she did have some skin lesions. However, dermatology consultation with Dr. Kato suggested this was most likely methotrexate related. She was given intravenous leucovorin and high dose prednisone treatment. This along with her intravenous fluids stabilized her condition. At the time of discharge her oral ulcers had markedly decreased; she could sallow without difficulty and her p.o. intake was adequate.…
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.…
In Matter of R.D.B., 1996 Tex. App. LEXIS 2932 (Tex. App.-Beaumont, 1996), R.D.B. was a sixteen-year- old who committed robbery and unauthorized use of a motor vehicle, both of which are felony charges. At the time of R.D.B.’s arrest, he was on probation for an earlier felony.…
PHYSICAL EXAMINATION: GENERAL: 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 sign: Blood pressure 140/90, temperature 98.3, pulse 97, and respiration 18.…
PAST MEDICAL HISTORY: Per-op blood glucose is noted to be greater than 200. The patient asked for a medical consult/admission for further evaluation. Currently he denies chest pain and shortness of breath. No dysuria, no increased urine infrequency. Past history is significant for hearing loss in the right ear subsequent to an assault several years ago. Past surgical history includes a lower back surgery and the left ankle surgery.…
GENERAL: 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.…
The patient was transported from home by her daughter-n-law. According to patient daughter-n-law she has been complaining of pains in her right leg approximately one day. Family administered daily pain medications that did not help the condition of her persisting pain. After pain persisted daughter in law later brought the patient in to the emergency room for examination.…
daughter insisted on taking him to the ED for evaluation. After orienting him to the room, call light, bed controls, and lights, you perform your physical assessment. The findings are as follows: he is awake, alert, and oriented (AAO) \3, and he moves all extremities well (MAEW). He is restless, is constantly shifting his position, and complains of (C/O) fatigue. Breath sounds are clear to auscultation (CTA). Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm (RRR). Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. A sharp inspiratory arrest and exclamation of pain occur with deep palpation of the costal margin in the RUQ (positive Murphy’s sign). He reports light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. Skin and sclera are jaundiced. Admission vital signs (VS) are 164/100, 132, 26, 36° C, SaO2 96% on 2 L of oxygen by nasal cannula (O2/NC).…
What have you determined, based on your assessment, to be key information that the patient needs to know/learn?…