Erin is a 33yo, G3 P1101, who was seen for an ultrasound evaluation and consultation. The patient has a longstanding past history of substance abuse as well as alcohol abuse and she is HIV positive with a positive viral load. She is followed by infectious disease and is on numerous medications including Genvoya and Prezista. She also is reportedly hepatitis C positive. She has a history of alcohol abuse in the past but states that she has not had any alcohol since early June. Her LMP was 08/06/17. She also has a history of cocaine usage but again denies any usage in the past year. She does have a longstanding history of physical abuse and has had issues with anxiety. She has 2 previous deliveries. The 1st of which was in 2004 that occurred
PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia noted. No edema noted in extremities. Patient skin is cool to touch, slightly clammy. EEG shows prolonged QRS wave, with ischemic ST changes and PVCs. Chest radiograph clear.
It is our pleasure to see and provide FTS for Ms. Jennifer Mullins. She is a 19yo, G1 P0, with EDD by an 8-week 1-day ultrasound performed in your office giving an EDD of 12/25/17. Her past medical history is notable for morbid obesity with a prepregnancy BMI of 45. She takes prenatal vitamins, denies any surgical history, is normotensive with a normal urine dip here. This is her 1st pregnancy. Her social history is negative x3. Her family history is notable for breast cancer, HTN, diabetes in her maternal grandmother, and heart disease in her as well. She has having occasional nausea, vomiting, and heartburn and says that the Diclegis is not working at all and would like a different prescription.
In transport, patient received O2 at 4 liters via nasal cannula, baseline EKG, Normal Saline IV started in left hand, 325 mg aspirin by mouth (po). Patient complained she was short of breath and experiencing severe pain between her shoulder blades. She stated that she has been feeling nasuseated for the past 3 hours. She states she has a history of stable angina and is currently taking medication as needed. She states she did not take the nitroglycerin because she was not experiencing chest pain, just back pain. She states that her last check-up with the Pulmonologist showed that her EKG did not show any changes since her last visit. She denies episodes of syncope. The patient does report that she tripped over something on the floor, which resulted in her falling and hitting her back on a large table. In addition, she states that her heart rate has been ranging from 130/ 90 to 140/92. Patient states her Primary care physician placed her on blood pressure medication 2 months ago due to the increase.
My patient is a 58-year-old female, who presents with controlled type II diabetes, hypertension, and possibly thyroid tumors that have been there for a few years. She is under the care of a physician for her diabetes and associated controlled hypertension. I recommended several times that she see her physician after feeling the tumors around her neck and thyroid. Her medical history also indicates that she had rheumatic fever twelve to thirteen years ago, has arthritis in her knees, and occasional headaches. She is 5”3 and weighs 216 pounds. Her blood pressure was 126/80, pulse was 88 BPM, respirations were 20, and her temperature was 98.2 Fahrenheit. She doesn’t smoke and I made sure that she had eaten lunch and wasn’t hungry. She is currently on 100 mg Metformin for her diabetes, 120 mg. Lisinopril for hypertension, 40 mg. of Lovastatin to lower cholesterol, 80 mg. of Aspirin to prevent cardiovascular disease, and daily insulin. Reviewing her medical HX, I was informed that she usually checks her blood glucose daily, but had recently run out of strips, so it had been a
It is our pleasure to see and perform FTS on Ms. Kaylyn Houser. She is a 16yo, G1 P0, with EDD by LMP consistent with an 8-week 4-day ultrasound performed in your office. The patient has a history of anxiety and what sounds like bipolar disorder, narcolepsy, and sleep apnea, as well as prepregnancy BMI of 32. She was previously on Lamictal, Luvox, and magnesium when she started the pregnancy and comes today attempting to wean from the Lamictal currently taking 100 mg daily. Her surgical history is notable for ankle surgeries. She has no prior pregnancy history. Her social history is negative x3. Her registration BP is 137/81. Her urine dip is negative for protein.
N.L. has history of constipation and fecal impaction several years ago. Patient also has history of Diabetes Mellitus type 2 for 9 years, Hypertension for 15 years, and Chronic Obstructive Pulmonary Disease (COPD) for 5 years. Patient has also had laparoscopic appendectomy 5 years ago for erupted appendicitis and total hysterectomy 3 years ago due to uterine fibroids. N.L. smoked half a pack of cigarettes for 20 years and recently cut down to 2 cigarettes per day. N.Ll also drinks alcohol occasionally, approximately 2 drinks per month.
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.
The following case scenario is based on a fictitious patient, and it would be use on this paper as a guidance to develop a patient and family teaching plan. The situation: Mrs. Marquez, a 39-year-old Caucasian female was admitted into the Emergency Department due to complains of shortness of breath and anxiety. Patient cannot take deep breaths, appears overweight and denies Allergies to medication. The background: Patient has medical history for panic attacks, atrial fibrillation, and Grand Mal seizures; however, patient is not constantly taking her seizure medication. Patient previously had a cholecystectomy, and smokes 1 pack of cigarettes per day for 12 years. The Assessment: Patient vital signs 98.8° F oral, 109 heart rate, 26 respiratory rate, 150/86 blood pressure, SaO2 97% on room air. Denies pain. Neurological; Patient is 65 inches tall, weighing 246 lbs. She is able to move all extremities with strong pushes and pulls. States her “last seizure was two months ago.” Respiratory; Respirations are even, deep, and rapid. Lungs are clear on auscultation. Cardiac; EKG reveals atrial fibrillation; patient states, “It feels like my heart is racing at times.” Pulses are palpable +3 all extremities; capillary refill is instant. GI; Abdomen soft, no distended, and no tender with bowel sounds present in all four quadrants; skin is intact and warm. Current medications: Dilantin 400mg PO BID, Lexapro 20mg PO daily, Metoprolol 25
The patient is a 72-year-old black female who presented to the ED with complaints of low blood sugar. Her son found the patient at home in bed unresponsive. The son states he checked the patient's blood sugar it was 47. The patient is on NovoLog 3 times a day and Lantus one time a day. The patient had similar symptoms in the past. The patient has a medical history of dementia. She also is known to be hypertensive, insulin-dependent diabetes and has no surgical history. It is to be noted on presentation her BP was 128/95 with a pulse of 52, respirations of 15, hypothermic with a temp of 93 and oxygenating 94% on room air. She also showed significant bradycardia. EKG at 48 beats per minute, T waves were inverted in leads 4, 5 and 6 but
During our initial assessment of Ms. K.R., the following vital signs were noted: blood pressure was 147/67, temp 36.6 degrees Celsius, pulse 80 beats per min., respiratory rate of 20, pulse ox 99% on room air, a pain score of 8 during contractions, and fetal heart tones had a baseline of 130 over the last two hours. Her labs showed 2+ protein in her urine but she denied any headaches, vision changes, right upper quadrant pain, and no DTRs or colonus were observed. Ms.K.R. seemed to be handling her labor well, with the exception of being in a lot of pain and unable to find a comfortable position.
D.E is a 58-year-old white female who has been living with chronic illness, Chronic obstructive pulmonary disease (COPD), for 6 years. A definitive diagnosis, wasn't made until 2010, four years after the onset of the symptoms. She recalls, having a past medical history of sleep apnea, and chronic bronchitis with frequent admission in the hospital from pneumonia. She reports a past surgical history of an abdominal bilateral tubal ligation at the age of 26 years old. Mrs. D.E. reports using Continuous Positive Airway Pressure Machine (CPAP), Robitussin for cough/chest congestion, Proair-HFA two puffs every 4-6 hrs P.R.N for breathlessness and an occasional Tylenol at the onset of her symptoms occurred. She reports a one pack per
Mary Martinez is a 72 year-old female that is here in Prep and Holding for a scheduled elective right knee replacement surgery. I am performing a final pre-op exam at 6am. The patient is awake, alert, and oriented to name, place, and date. Patient has no known allergies. Patient stated her past medical history included: atrial fibrillation, hypertension, coronary artery disease, Type II diabetes mellitus, hyperlipidemia, and osteoporosis. Medications were reviewed with patient. Patient stated taking Coumadin, aspirin, metformin, metoprolol, calcium, and simvastatin. The last time, she has taken her medications were last night at 2000, including her warfarin and aspirin. She has been NPO since midnight. Physical assessment was performed. Patient complains of chronic pain in the right knee. Pupils are equal and reactive. Lung sounds are clear with auscultation on all lobes without any respiratory distress noted. Respiratory rate is 18 breaths per minute. Patient is on room air with oxygen saturation of 97%. Heart sounds are irregular with no murmur noted. Heart rate ranges from 92 to 120 beats per minute (bpm). Blood pressure is 140/67. Labs were reviewed. Abnormal values were International normalized ratio (INR)