51 Year Old Afc Case Study

At today’s visit she is found sitting in the chair, she is awake, alert, and confused. I am asked to seek this pain for new onset pain. The patient complains of acute pain in pubic area and right hip area, pain is dull, achy, severity 4/10, pain is worse with walking. At this time the patient is not taking anything for pain. The ALF staff reports that the patient has daily anxiety and has to be given Ativan three times daily. The patient ambulates with a walker. Gait is

2/10/2016, 1600, Vital Signs: BP 140/85 P132 RR32 Temp 102.2 SpO2 85% on 2 liter by nasal cannula. Jacquline Catanzaro is 45 years old female on disability admitted to Medical Unit Hospital. Sister with patient. Reason to admit is can’t breathe. Diagnosis is 30 year of asthma exacerbation, psychiatric schizophrenia, obesity, pneumonia and herniated disc. Smokes 40 packs year. Drinks 2 pots of coffee a day. Drinks 3 beers each day. Frequency ED visits and hospitalization dependence on rescue inhaler. Patient refuses wear nasal cannula because of worry that it contains poison. Patient has a long history of stopping taking psychiatric medication and asthma medications. Patient has isolated herself from others. Sister is only caregiver. Neuro

Mr. XXXX is a 44 years old Caucasian male, a general construction worker who works on a nearby highway for the bridge project, and checked in this urgent care center for complaining of chest pain and shortness of breath (SOB). The chest pain is constant dull and pressure like pain, and started 3 hours ago. The pain is located on the center of chest. He rates the pain 4 out of 10 on a pain scale 0 to 10 while resting. The pain gets worse and increases after eating. He experienced increased chest pain and SOB with simple walking from the parking lot to this office. The pain was not resolved with taking PO 365mg of Aspirin 2 hours ago and resting. He was diagnosed with hyperlipedemia 10 years ago. He is taking medication to manage his high cholesterol level. He denies past history of chest pain, hypertension, and coronary artery disease. He denies any history of heart surgery or cardio artery bypass surgery. He is anxious and fearful for his first chest and SOB. He smokes a half pack a day for past 20 years. He drinks one bottle of bear every evening with meals. He denies taking any herbal medication or illicit drugs. He has been a good appetite. He reported 20 lbs weight gain since his retirement from military. He has an irregular meal time and does not exercise as much as he used to do in the military.

This is 51 year old AAF. Patient is here for general physical exam for Medicaid application. Patient states that she has a pancrititis. For that reason, she can only perform vare minimal activities. Patient sates she cannot work for that same reason. Patient denies chest pain, reports SOB with minimal activy, denies N/V/ D, or fever. Patient denies depressive moods.

HPI (History of Present Illness): The patient is a 65-year-old Caucasian female with symptoms of dry cough for the past two weeks, low grade fever for two days, and decreased appetite that have been deteriorating with time. She also experiences shortness of breath (SOB) with activity. She was treated for similar symptoms three months ago with antibiotics and an inhaler and some improvement was noted in her condition. At the moment she is seeking medical attention as she is concerned about her fever and prolonged illness.

According to the provider, the claimant's cough has been improved. His review of systems was positive for fatigue, malaise, sleep difficulty, shortness of breath, wheezes, and a cough. His blood pressure was 115/71 mmHg and his BMI was 30.35 kg/m2. The physical examination revealed wheezes. Clonazepam was prescribed for agitation. Atorvastatin, Nystatin, Citalopram, and a probiotic were prescribed. Continued use of Aspirin and a regular inhaler were suggested. Further, a follow-up visit with Endocrinology, Cardiology, and Pulmonology. As it relates to a spot in his lung, a repeat CT scan was recommended. The bronchial washes were negative for

Patient “DD” is a 56-year-old woman who was admitted to a nearby hospital for respiratory failure. With the only previous medical history being chronic bronchitis, she was diagnosed upon admission with COPD, anemia, hypoxia, moderate anxiety, and dyspnea.

HPI: Margaret Elliot is a 52-year-old Caucasian female that is presenting with shortness of breath that has recently worsen. Mrs. Elliot states that her problems began 20 years ago when she had bronchitis, which she consistently has 2-3 times a year. She said that her symptoms have been getting worse the last 2.5 month, but have severely worsen over the past three days. She states that it has been restricting her daily activities and has been troubling her while sleeping lying down. She states that her symptoms improve alittle when she takes her medications. She also states that her symptoms worsen when she tries to walk across the room

The patient is alert and oriented to person, place, and time. Upon initial interaction, the patient is easy to communicate with and states she is doing well. Facial features are uneven and asymmetrical, as she has a slight left facial droop due to her stroke, which she states happened a couple of years ago. DG expresses multiple times that she has a hard time seeing and she wears prescription eyeglasses. PERRLA. Skin is pink, warm, dry; temperature is 97.5 and turgor is brisk. There is a 20 gauge IV in the right hand infusing Lactated Ringers at 20ml/hour per pump, no redness or edema noted at the insertion site. Respirations are even and non-labored at 22 breaths per minute. Lung sounds are bilaterally clear. The client has a nasal cannula infusing 2 liters of oxygen with an oxygen saturation of 96%. DG tells me she is a current smoker and she smokes

S: MJ is a 74 year old African-American female who presents to the clinic today with complaints of shortness of breath with exertion and increasing fatigue over the past two to three months. The shortness of breath is increased with exercise or when walking up stairs and has progressively gotten worse. She states that she presented to the emergency room approximately one year ago for shortness of breath and was prescribed an albuterol inhaler. She additionally has a chronic productive cough with clear sputum and denies hemoptysis. She has had no recent upper respiratory infections and denies fever. She denies chest pain or tightness. She also states that she has noticed some ankle edema over that has developed over the past

----- Clinic presents a black male 68 years old. Currently experiencing dyspnea and lethargy. For the past week he has been having a increase of difficulty breathing. Complains of alternating periods of sweating and chills. Other symptoms he has been experiencing is a productive cough with expectoration of thick yellow sputum. Patient is a ex- smoker, he was a 40 pack year history, denies smoking, stopped over 10 years ago. Medical history includes chronic bronchitis, hypertension, MI five years ago, has had a angioplasty, and denies chest pain since having angioplasty. Current medication combined albuterol/ipratropium MDI, nebulized albuterol prn, captopril, and hydrochlorothiazide.

This is 39 year old AAM. Patient is here with several complaints. Patient has no medical condition, or long term medications. Patient denies any other issues except as listed.

This is 35 year old WM. Patient was seen at UAB ED for UTI and kidney stone on 3/30/2016. Patient was discharged with roboxin and ibuprofen. Patient has a history of Hep C, was told about 12 years ago, and was retested at UAB and HVC was positive. Patient is a current resident at the Villige. Patient has a history of substance abuse, denies current use, last use about 10 days ago. Patient is a current tobacco user, denies use of alcohol or illicit drugs. Patient reports some depressive moods, denies thoughts of suicide or

Respiratory: Patient denies having history of lung diseases such as asthma, emphysema, bronchitis, pneumonia, or tuberculosis. She also denies having chest pain with breathing, wheezing or noise breathing, shortness of breath, hemoptysis, sputum, toxin or pollution exposure. Patient states that she had common cold with some productive cough for about a week last month. Also, patient states that occasionally she experiences shortness of breath when she runs for more than 40 minutes. Patient states that her last chest x-ray was 1 years ago, and the results were negative.

Patient is a 71 years old female who is from assisted living who presents in the Emergency department due to tachycardia and chest pain. Her symptoms started before going to bed and she felt like her heart rate was racing and felt short of breath. EMS was called and patient states her shortness of breath improved after 12 mg adenocard was given by the EMS. Patient has a medical history of senile nuclear sclerosis, anxiety, hypertension, diabetes, heart disease, asthma, heart attack, copd, renal insufficiency, palpitations and cataract removal. Patient is taking 22 medications in the assisted living. She was then admitted in our telemetry unit with a diagnosis of chest pain. Upon arrival in the unit, patient was Alert and Oriented to name,