TRANSITION OF CARE: EVERYONE’S RESPONSIBILITY Describe the patients medical/clinical condition. This past December I observed the discharge of a patient from the Emergency Department that never should have taken place. The patient was a senior citizen who suffered a fall injury‚ and was diagnosed with bilateral humerus fractures. Her injuries did not require immediate surgical intervention and her pain was relatively well controlled. Therefore‚ the physician caring for her did not find it medically
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DISCHARGE SUMMARY Patient Name: Adela Torres Patient ID: 132463 DOB: Age: 57 Sex: Female Date of Admission: 6/22/---- Date of Discharge: 6/25/---- Admitting Physician: Liam Medina‚ MD Consultations: Sachi Kto‚ MD‚ Dermatology Procedures Performed: Intravenis Hydration Complications: None Discharge Diagnosis: 1. Methotrexate related dermatitis. 2. Rheumatoid arthritis class 3 stage 4 3. Osteoporosis
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EMERGENCY SERVICE ADMISSION REPORT Patient Name Brenda C. Brenda C. Seggerman Patient ID: 903321 Date of Admission: 03/27/---- Emergency Room Physician Alex McClure MD Admitting Diagnosis Ectopic pregnancy CHIEF COMPLAINT: The patient presents to the emergency room this morning complaining of lower abdominal pain. HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding‚ more like spotting‚ over the past month. She denies the chance of pregnancy‚ although
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RAFT Task 3 Tracer Patient summary: A 67year old female patient was scheduled for a laparoscopic hysterectomy. However 5 weeks prior to hospitalization she was hospitalized and the case was converted to an open procedure due to excessive bleeding. After being discharged she developed fever and drainage and was readmitted again for possible postoperative infection seven days ago. On day two of admission she underwent surgery for post operative abscess and insertion for a central line for long-term
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DISCHARGE SUMMARY Patient Name: Adela Torres Patient ID: 132463 Date of Admission: 6/22/---- Date of Discharge: 6/25/---- Admitting Physician: Leon Medina‚ MD‚ Internal Medicine Consultations: Sachi Kato‚ MD‚ Dermatology Procedures Performed: Intravenous Hydration. Complications: None. Admitting Diagnosis: Stomatitis possibly methotrexate related. HOSPITAL COURSE: This 57-year-old Cuban female was admitted from my office for treatment of severe stomatitis
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DISCHARGE SUMMARY Patient Name: Adela Torres Patient ID: 132463 Date Admitted: 06/22/2013 Date Discharged: 06/25/2013 Admitting Physician: Leon Medina‚ MD‚ Internal Medicine Consultations: Sachi Kato‚ MD‚ Dermatology Procedures: Intravenous hydration. Complications: None. Admitting Diagnosis: Stomatitis‚ possibly methotrexate related. HOSPITAL COURSE: This 57-year-old Cuban female was admitted from my office for treatment of severe stomatitis and mild volume
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Discharge Teaching Plan Patient History Patient is a white female admitted with Mood Disorder NOS and R/O Bipolar Disorder. She has a strong family history—mother is positive for Bipolar Disorder and Anxiety Disorder and has attempted suicide 3X since January. Her uncle is positive for Personality Disorder. Patient was raped at her stepfather‚ sexually abused by her Grandfather whom she resides‚ and physically abused by her biological father whom she resided with for 6 months‚ prior to moving
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Bob Wiley is a white male in his 30’s and suffers from multiple phobias and anxieties that are associated to the phobias. The patient Bob breaks client/therapist relationship from the start. However‚ the session that Dr. Marvin did not indulge in the ethical and confidentiality aspects to have the client be made aware. Patient Bob continues to violate personal boundaries. Dr. Marvin tries to utilize techniques to have Bob return home‚ however it does not have Bob return it makes him feel more connected
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DISCHARGE SUMMARY Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/5/---- Age: 46 Sex: M Date of Admission: 11/14/ Date of Discharge: 11/17/ Admitting Physician: Bernard Kester‚ MD Discharge Diagnosis: acute superative appendicitis perforated Surgical Procedures: Laparoscopic appendectomy with placement of RLQ drain on 14 November. Complications: none. DIAGNOSTIC LAB/IMAGING: Lab results at time of admission showed a WBC count of 13. CT scan done in the ED revealed
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DISCHARGE SUMMARY Patient Name: ENGELHART‚ Benjamin Patient ID: 112592 DOB: 10/5/1967 Age: 46 Sex: Male Date of Admission: 11/14/2012 Date of Discharge: 11/17/2012 Admitting Physician: Bernard Kester‚ MD‚ General Surgery Procedures Performed: Laparoscopic appendectomy‚ with placemat of right lower quadrant drain 11/14/2012 Complications: None Discharge Diagnosis: Acute suppurative appendicitis‚ perforated. DIAGNOSTIC LAB/IMAGING: Lab results
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