Surgeries: A Social History
Friday, patient felt something in her throat coughed it out and found that it had a chunk of red blood she photographed this and shows the photograph of the chunk that she coughed out and had no more of this until today, and then she felt something in her throat coughed out and had blood. She also had about a month of seeming to have a feeling as if food catches as she eats and has had some nausea but without vomiting and she has also noted a lump on her low back for approximately a month. This is in roughly an area where she has previously had back pain for years and takes medication for back pain. She states that she has previously been treated for cancer and multiple poor health problems and for her heart. She also notes a bitter taste
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She has had a recent brain scan with contrast.
SOCIAL HISTORY
Positive for smoking.
PHYSICAL EXAMINATION
VITAL SIGNS: Temperature 98.6, pulse 88, respirations 18, blood pressure 131/69, oxygen saturation 96% on room air. She appears to be in only mild distress and she does appear to be anxious.
HEENT: Her eyes are normal to inspection except her right pupil is larger than than the left and does not react to light. Conjunctiva is normal. Nose is not bloody. The mucosa may be slightly extra pink. Pharynx is normal. Airway is clear. Speech is distinct. No blood is seen in her mouth.
NECK: Supple. No adenopathy.
CHEST: There is no respiratory distress. Breath sounds are normal.
ABDOMEN: Tender in her right lower quadrant only. Bowel sounds are …show more content…
Motor and sensory function are normal. Affect does seem to be somewhat flattened for the extent of the illness she reports, but there is some mood swings as it would seem to be appropriate.
LABORATORY DATA
Data gathered includes white count of 9.5, hemoglobin is 14.1, glucose is 100, BUN is 15, creatinine 0.92, sodium of 140, potassium of 4.0, chloride 103, CO2 of 29.9, calcium is 9.1, bilirubin 0.22, alkaline phosphatase 104, ALT of 18, AST of 13. Urinalysis has specific gravity of 1.020, pH of 5.5, no white cells, no red cells. Chest CT was done. Radiologist describes chronic periapical pleural parenchymal scar and mild bibasilar subsegmental atelectasis. No active infiltrates.
EMERGENCY DEPARTMENT COURSE
When this data was gathered and reported back to her she was asleep and awakened by her friend both speaking to her and touching her and she awoke appropriately and full seemed comfortable at that time and had no apparent airway difficulty. She is advised to contact and continue care with her own physician. Call him tomorrow and continue care. No medication was thought appropriate at this time and she is to continue her regular
She has had a recent brain scan with contrast.
SOCIAL HISTORY
Positive for smoking.
PHYSICAL EXAMINATION
VITAL SIGNS: Temperature 98.6, pulse 88, respirations 18, blood pressure 131/69, oxygen saturation 96% on room air. She appears to be in only mild distress and she does appear to be anxious.
HEENT: Her eyes are normal to inspection except her right pupil is larger than than the left and does not react to light. Conjunctiva is normal. Nose is not bloody. The mucosa may be slightly extra pink. Pharynx is normal. Airway is clear. Speech is distinct. No blood is seen in her mouth.
NECK: Supple. No adenopathy.
CHEST: There is no respiratory distress. Breath sounds are normal.
ABDOMEN: Tender in her right lower quadrant only. Bowel sounds are …show more content…
Motor and sensory function are normal. Affect does seem to be somewhat flattened for the extent of the illness she reports, but there is some mood swings as it would seem to be appropriate.
LABORATORY DATA
Data gathered includes white count of 9.5, hemoglobin is 14.1, glucose is 100, BUN is 15, creatinine 0.92, sodium of 140, potassium of 4.0, chloride 103, CO2 of 29.9, calcium is 9.1, bilirubin 0.22, alkaline phosphatase 104, ALT of 18, AST of 13. Urinalysis has specific gravity of 1.020, pH of 5.5, no white cells, no red cells. Chest CT was done. Radiologist describes chronic periapical pleural parenchymal scar and mild bibasilar subsegmental atelectasis. No active infiltrates.
EMERGENCY DEPARTMENT COURSE
When this data was gathered and reported back to her she was asleep and awakened by her friend both speaking to her and touching her and she awoke appropriately and full seemed comfortable at that time and had no apparent airway difficulty. She is advised to contact and continue care with her own physician. Call him tomorrow and continue care. No medication was thought appropriate at this time and she is to continue her regular