Esophagus Case Study
Chapter 3 – Medical Record
History of Present Illness
Patient- 33 year old female was brought into ER with severe burning abdominal pain, nausea, and diarrhea. Patient has regurgitated once, light red in color. Patient stated that she has had pain several days, which she has been able to control with OTC-Ranitidine 75mg. This evening pain was worse and nothing was able to ease it.
Patient is heavy smoker- 2 packs a day and an occasional drinker- 1-4 drinks a month.
Possible pregnancy-2 months.
Past Medical History
Patient was diagnosed in 2010 with GERD and has damage to esophagus as a result.
Physical Examination
Patient is pale, perspiring profusely, and doubled over in pain.
BP-178/87
Pulse- 90
Temperature- …show more content…
Want endoscopy performed to check status of damaged esophagus from previous GERD diagnosis.
Two Questions for prospective hires
Do you think patient is a candidate for Esophageal cancer due to the prior damage of the esophagus?
What are the chances of the patient’s ulcer healing, if she refuses to quit or cut back on smoking and the occasional drinking?
References
http://www.nlm.nih.gov/medlineplus/pepticulcer.html
http://www.mayoclinic.org/diseases-conditions/peptic-ulcer/basics/definition/con-20028643
Chapter 4 – Medical Record
History of Present Illness
31 year old male patient has been evaluated by me on 9/1/2013 complaining of severe pain in all four quadrants of the abdominopelvic area, ventral and dorsal. Painful urination, with persistent urge to urinate. Patient is nauseated
Past Medical History
Patient has had past medical history of kidney stones most have been passed by patient, but in 2009 patient received two lithotripsy treatments and has ethereal stent in place.
No prior history of …show more content…
pulse 112, temperature 99.3
General- Patient is agitated and unable to get comfortable.
Heart- Irregular heartbeat, palpitations
Chest- normal intercostal retractions.
Diagnostic/Lab Results
CBC- elevated white blood count, with higher levels of calcium
Urine test- cloudy, trace of blood.
CT scan- detected three small stones in urinary tract
Impression/Discussion
Patient has kidney stones, no blockage, able to urinate. The patient was sent home with PERCOCET 5 mg 1 tablet every 6 hrs. Follow up with family physician. Suggest if patient does not pass stone in next 24 hours or pain does not subside; come back to ER for ureteroscope removal of stones.
Two Questions for prospective hires
Do you think patient’s kidneys may be damaged because of the lithotripsy treatment?
Should the patient be referred to an urologist for more specific treatment and possibility of dissolving the stones with proper medication?
References http://kidney.niddk.nih.gov/kudiseases/pubs/stones_ez/ http://www.urologyhealth.org/urology/index.cfm?article=148
Chapter 5 – Medical
History of Present Illness
Patient- 33 year old female was brought into ER with severe burning abdominal pain, nausea, and diarrhea. Patient has regurgitated once, light red in color. Patient stated that she has had pain several days, which she has been able to control with OTC-Ranitidine 75mg. This evening pain was worse and nothing was able to ease it.
Patient is heavy smoker- 2 packs a day and an occasional drinker- 1-4 drinks a month.
Possible pregnancy-2 months.
Past Medical History
Patient was diagnosed in 2010 with GERD and has damage to esophagus as a result.
Physical Examination
Patient is pale, perspiring profusely, and doubled over in pain.
BP-178/87
Pulse- 90
Temperature- …show more content…
Want endoscopy performed to check status of damaged esophagus from previous GERD diagnosis.
Two Questions for prospective hires
Do you think patient is a candidate for Esophageal cancer due to the prior damage of the esophagus?
What are the chances of the patient’s ulcer healing, if she refuses to quit or cut back on smoking and the occasional drinking?
References
http://www.nlm.nih.gov/medlineplus/pepticulcer.html
http://www.mayoclinic.org/diseases-conditions/peptic-ulcer/basics/definition/con-20028643
Chapter 4 – Medical Record
History of Present Illness
31 year old male patient has been evaluated by me on 9/1/2013 complaining of severe pain in all four quadrants of the abdominopelvic area, ventral and dorsal. Painful urination, with persistent urge to urinate. Patient is nauseated
Past Medical History
Patient has had past medical history of kidney stones most have been passed by patient, but in 2009 patient received two lithotripsy treatments and has ethereal stent in place.
No prior history of …show more content…
pulse 112, temperature 99.3
General- Patient is agitated and unable to get comfortable.
Heart- Irregular heartbeat, palpitations
Chest- normal intercostal retractions.
Diagnostic/Lab Results
CBC- elevated white blood count, with higher levels of calcium
Urine test- cloudy, trace of blood.
CT scan- detected three small stones in urinary tract
Impression/Discussion
Patient has kidney stones, no blockage, able to urinate. The patient was sent home with PERCOCET 5 mg 1 tablet every 6 hrs. Follow up with family physician. Suggest if patient does not pass stone in next 24 hours or pain does not subside; come back to ER for ureteroscope removal of stones.
Two Questions for prospective hires
Do you think patient’s kidneys may be damaged because of the lithotripsy treatment?
Should the patient be referred to an urologist for more specific treatment and possibility of dissolving the stones with proper medication?
References http://kidney.niddk.nih.gov/kudiseases/pubs/stones_ez/ http://www.urologyhealth.org/urology/index.cfm?article=148
Chapter 5 – Medical