Case Based Approach : Patient Information

Clinical day started slow, I was a bit anxious about waking my patient up that morning but I knew I had to go in. I woke him slowly and took his vitals and proceeded with my assessment. As I assessed my patient, his wife came in to his room and I introduced myself. During the morning I found out that my patient was being discharged. Before discharge, my patient was going to be fitted for a LifeVest.

The patient had a sudden onset of lower left quadrant pain and was diagnosed with

The patient complained of right lower quadrant pain and of feeling faint. Dr. O'Donnel documented a chief complaint, a brief history of present illness, and a systemic review of the gastrointestinal system and respiratory system. Dr. O'Donnel also documented a complete examination of all body systems, which included all required elements. Medical decision making was of moderate complexity.

This patient presented to the emergency department (ED) with pain in his upper right quadrant and flank. He reported experiencing abdominal distention

Mr. Steward was pain free until this morning. He initially complained of right-sided chest pain and then complained about pain in his hip and ankle. We recognized this was a new onset of pain that persisted, despite giving him some pain medication. When Mr. Steward was discovered in his room clutching his chest, we recognized this as a non-verbal sign of pain and asked him whether he was having chest pain. Although Mr. Steward doesn 't provide a definitive answer, he displayed non-verbal signs of pain, such as restlessness, frequent shifting in bed, and act of clutching his chest. Recognizing Mr.

During my rotation there I observed patients coming in with chest pain and abdominal pain. The patients with chest pain had an

My Story: Today, was an awesome, extremely busy clinical day; I absolutely loved it. I saw five total patients. The first patient that I saw was with Laura, this patient was diagnosed yesterday, 2/7, with cirrhosis of the liver and HEP C. The patient’s chart says he has a history of anxiety, however, the patient stated that his anxiety started when he was told in the ER on 1/25 that he could have cirrhosis of the liver (more information in part D and E). This patient was very interesting, and I was amazing by how much he was going through; I felt bad for him. I did vital signs and my part D and E with this patient, and built a therapeutic relationship with this individual. I completed my part D and E on my first patient, due to not knowing if other patients were going to cancel because of the snow, as well as I didn’t know what patients I could see because the NP, Tanya wasn’t in the office in the morning. At the end of the visit, the patient asked me if I would be coming back again. This made me feel good, because I knew listening and being there as support for this patient helped him. The rest of the day I followed the

P-The patient was strongly encourage to attend the Women's Group on 02/29/2016 and update this writer with any assistance until she is assigned with a

D-According to the patients she has a surgery on 04/22/2016 for stems in both legs. The patient signed an ROI for Dr. Vandisht for this writer to contact the doctor to obtain a letter stating that the patient can inf fact dose on the day of her surgery. The patient showed this writer with some improvement of her hand with a condition she is unfamiliar that her dermatologist gave her an ointment that cleared her skin. The patient is scheduled to see her dermatologist on 04/29/2016. The patient spent the session discussing an issue with her Fern Manor and its staff members. The patient then signed a ROI for her Pulmonary Doctor. There's still no communication with her older daughter, but the patient still reaches out to her daughter.

O: Inspection of the right shoulder, no redness or edema noted; palpation of the right shoulder there was no warmth noted; on deep palpation TM reports in some tenderness

On Primary Treating Physician’s Progress Report (PR-2) dated 08/11/2017, the patient presented with unchanged symptoms. His left-hand pain was rated at 8/10. and was described as constant and sharp. The pain was aggravated with certain movements and gripping. The

D-The patient reports she is stable on her current dose and haven't used any illicit drugs since her last encounter with this writer. The patient reports her due date regarding to the birth of her child is scheduled for 05/03/2016. Futhermore, the patient is excited that she got her engagement and looking towards to planning her wedding next year around Halloween. The patient's missed the take home bottle group due to not feeling well.

D/A: There were no medical appointments for Mr. Brown this week. Mr. Brown attended dialysis twice this week on 01/03/17 and 01/7/17 at the Fresenius Medical Center and received treatment on 01/5/17 at the Kent General Hospital. On 12/31/16, Mr. Brown was admitted to the Kent General Hospital and was discharged on 01/07/17 at 7 pm, where he was diagnosed and treated for Pneumonia and Congestive Heart Failure. Consumer has a new addition medication “Prednisone,’’ that he will be taking once in the morning for three consecutive days. Consumer did not meet with his Psychiatrist Dr. Capiro this week because he was admitted at Kent General Hospital.

Thoroughly document the details of all patient contact – including in person, by phone, or by written correspondence – in the patient’s chart. Simply writing “patient noncompliant” is not sufficient. A properly-constructed note should include:

D-The patient arrived on time for her sessions. Reports stable on her dose and denies the need of cravings/withdrawals. During of the counseling sessions, the patient discussed about how she spent her 4th of July and her fear of swimming. Then the patient shares about conducting a pap smear at Charter Oaks and is now assigned with a new PCP. She's scheduled to meet with the PCP on 07/21/2016-bloodwork results and another appointment is scheduled on 07/13/2016 for pap smear results.