Case Narrative For Er Admission Of Adam Rudd

A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he

Jack, the patient presented through Accident and Emergency to Ward D3, an acute medical ward specialising in respiratory medicine. He was admitted due to an exacerbation of dyspnoea, which was more significant over the last twenty-four hours. The writer met Jack on admission to the ward.

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

The patient has no family history of heart disease or diabetes, however both her parents are on medication for high blood pressure. Her paternal grandmother died of breast cancer at age 47. Her maternal grandmother

As Jane was presenting with a symptom of a life threatening event it was important that treatment was immediate. Priority was initially made from assessment of the airways, breathing and circulation, level of consciousness and pain. Jane’s respirations on admission were recorded at a rate of 28 breaths per minute, she looked cyanosed. Jane’s other clinical observations recorded a heart rate of 105 beats per minute (sinus tachycardia), blood pressure (BP) of 140/85 and oxygen saturation (SPO2) on room air 87%. It is important to establish a base line so that the nurse is altered to sudden deterioration in the patient’s clinical condition. Jane’s PEWS score (Physiological Early Warning Score) was 4 and indicated a need for urgent medical attention (BTS 2006). Breathing was the most obvious issue and was the immediate priority.

Pulse rate is at 72. The blood pressure was 140 / 95,which is suggestive of high blood pressure and related to his medical history. No heart murmur was noted, and no other abnormalities were noted.

2. An 56-year-old established patient presents to her doctor's office with chest pain and shortness of breath. The doctor orders an ambulance to take the patient to the ED to be checked out. From the ED the patient is admitted for some

Meanwhile, elsewhere in Habersham County, Tom was feeling slightly nervous as he exited the staff lounge and entered the hustle and bustle of County Hospital’s ER to begin his first shift as an RN. The first few hours of his shift passed slowly as Tom mostly checked vital signs and listened to patients complain about various aches, pains, coughs, and sniffles. He realized that the attending physician, Dr. Greene, who was rather “old school” in general about how he interacted with nursing staff, wanted to start him out slowly. Tom knew, though, that the paramedics could bring in a trauma patient at any time.

States that it started 3 days back and uses oxygen at home. States that he is a former smoker and laying on his back feels better. Also says he has a list of medication, more than 20. Pt has a history of COPD, CHF, DM,morbid obesity, HTN, HLM, hypothyroid, and sleep apnea. Has no accessory muscle use. CC is shortness of breath. Assessment is that there is no deformities or trauma of the head or neck area. Chest shows no signs of deformities or trauma. The abdominal area is tender and warm to the touch. Pelvis and back was not assessed. The upper and lower extremities show signs of low circulation and swelling. PMS=4. I helped with placing the BP cuff on the left arm and attaching it to the monitor. First vitals were recorded. O2 was given by the Nurse and then Albuterol by nebulizer. After 30 minutes, I assisted the Nurse and other hospital workers in moving the PT to a bigger bed. Second set of vitals were recorded. After becoming stable the Pt was moved up to the floor.

The patient tells me his last visit with Peter Dourdoufis, MD was just last week. I do not yet have a note from that visit. He says that he underwent an EKG and a stress test evaluation. To his knowledge, everything was okay, but he actually has an appointment tomorrow with Dr. Dourdoufis to review everything. No medication changes have been made per his report. He tells me that his blood pressures have been in a good range. Here today, his blood pressure is 126/76. He is not having problems with chest pain, shortness of breath, dyspnea on exertion or lower extremity swelling. He is still working

Mr. S is a 29-year-old male with past medical history of (PMH) hypertension (HTN) and obesity who presented to local emergency room (ER) with headache and chest and back pain. Mr. s had been seen at urgent care three days prior for a headache and near syncope and was told to hold his metoprolol due to bradycardia. Due to health insurance related problem, he has been off amlodipine and lisinopril for a month.

Mr. Bellows is an overweight, 51-year-old with a long history of angina. He is known to your hospital and arrives in an ambulance with more severe symptoms than previous admissions. Mr. Farmer informs the ambulance crew, the Anginine tablets he has taken, have not provided any symptom relief.

This patient arrived on time for her scheduled appointment with this writer. This writer introduces herself as the patient assigned counselor, at which the patient was pleased to be assigned to a counselor. This writer discussed with the patient UDS and the patient's prescribed medication. According to the patient, she provided information of her current medical concerns such as the seven blockage with her heart, her chronic back pain- the patient reports that she needs to replace 2 or 3 discs, and her foot surgery. The surgery for the patient's heart and foot are pending at this time. The patient reports she is scheduled to conduct a sleep apena on 03/03/2016 and is aware that she must provide an update to Nursing at the clinic. The patient praised about having a excellent Cardiologist, who is currently monitoring her heart. the patient was emotional discussing the many loss of her family who suffers from congestive heart failure. The patient reports, " I believe there is a GOD and he is

A 70-year-old female with a 50-year history of uncontrolled hypertension despite a combination of antihypertensive agents that lastly includes: amlodipine 10 mg, spironolactone 25 mg, losartan 100 mg, and furosemide 40 mg; all were used once daily. She was referred to our center as a case of ADHF for further workup. On admission, the patient was in severe respiratory distress consistent with the New York Heart Association (NYHA) class III-IV and was orthopneic but fully conscious with normal cognition. Physical examination showed: a blood pressure of 153/93 mmHg, heart rate of 117 beats per minute, respiratory rate of 28 breaths per minute and oxygen saturation of 94% on BiPAP. She had bilateral basal crepitation, bilateral scattered rhonchi,

Patient is a 45 yo male; 5’7”, 221 lbs who entered the emergency room at 6:30 am on 9/7/14 with severe chest pain (onset at 6:00 am) radiating to his arm, L arm numbness and nausea and vomiting. Past medical history reported by wife includes peptic ulcer, tobacco use (1-2ppd for 27 years), elevated blood pressure (controlled by lopressor). Wife did not know of any family history but reports patient’s father is deceased, died at 42 in his sleep. Mother alive and with high blood pressure.