Oct 1st This was the first day on the floor and I got a patient that is a 49 years old female. Her past medical history was HIV/AID (+), untreated hepatitis C, HTN, asthma, chronic back pain, respiratory failure and SOB. She current diagnosed is meningitis, COPD, and sleep apnea. Client was oriented and alert x3 and ambulates independently with a steady gait. She is allergy to ciprofloxacin HCI, efavirenz, nevirapine, and oxcarbazepine. When asked for pain, she stated at her belly and lower back. She has a Picc line on her left arm that was a little resistance. Patient was given hydromorphone 2mg/mL IV, and promethazine 25mg IV. I was not able to assess much of her since every
A is an 87 year old women, with a long history of health troubles including chronic kidney disease, congestive heart failure, coronary artery disease, a pacemaker insertion for her atrial fibrillation, type 2 diabetes, dyslipidemia, colon cancer, breast cancer, mild cognitive impairment and most recently paranoid psychosis.
Patient L.H. is a 69-year-old married Caucasian male that is a retired teacher that lives at home with his
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.
This is 31 year old white male. Patient is here with several complaints as listed. Patietn was seen at UAB ED yeaterday for the same conditions and discharged without any treatment; "They don't like me there, UAB, because I have a long history of drug use and frequent use of their ER." Patient denies chest pain, SOB, N/V/ D. Patient is a current tobacco user with 20 apck year hisotyr. No substance abuse for the past 3 months. Current pain
Claimant reports history of multiple medical complaints. Since the age of 60 she reports struggling with urinary incontinence, which impacts her functioning at work. She reports feeling ashamed and guilty that she is unable to control her urination and has the need to periodically utilize the restroom or go to her car taking time away from her responsibilities. In the past few years claimant has severe intensification of physical symptoms, including back pain, right shoulder and hand weakness, blood pressure, headaches, sleep difficulty, and depression-related fluctuating appetite, fatigue and sluggishness. She reports experiencing heart palpitations present (racing heart), dizziness, and fear of actual fainting, a feeling of choking and not being able to breathe, chest pains, nausea or intestinal pains, shortness of breath, tremors in the hands, hot flashes and tunnel vision. The claimant reports that she sleeps very minimally; averaging 3-4 hours of sleep per night on an interrupted basis due to physical and emotional pain. She reports that she has very poor mobility due to pain and depression-related poor motivation.
This 54 year ld AAM. Patient has a history o fDM, HTN, and hyperlipidemia. Patient's current medications are Glipizide 10 mg BID, ASA 81 mg QD, Triamtereine /HCTZ 75/50 mg, Pravastatin 40 mg QHS, and lorsatan 300 mg QD. Patient states he is taking all mthe medications as prescribed, and he thought he was doing fine. Patient states no one in the Federal Prison System had checked his A1C in several years. The patient's A1C today is greather than 14 %. Patient denies buller vision, headache, chest pain, SOB, N/V/D, or fever. The patient denies decreased sensation of his feet, increased thirst or urination. Patient denies any depressive moods. The patient is here with his wife and had a long disussion with the plan of care for his DM, HTN, and
Past Medical history includes : Essential Hypertension, Cardiac pacemaker, Coronary Artery Disease, Dyspnea, Sensiosenural hearing loss, Restless legs, headache, acute hypothyroidism due to radiation, Mandible Cancer, Pseudophakia of both eyes, Posterior vitreous detachment, malnutrition, Generalized weakness, Smoker of 2 packs of cigarettes per day for 30 years.
Member experienced moderate pain due Dx. Osteoarthritis, have an unsteady gait, experiences dizziness (new medication Flomax 0.4 milligram) and is a risk of falling (score 11). He needs assistance of daily living. Goes to bathroom frequently due to Enlarged prostate.
Patient is a nineteen-year-old college student working as a CNA. Patient’s has multiple chronic conditions such as Celiac Disease, Spina Bifida, Sjogren, Malabsorptive Disorder, Gluten Intolerant, Anemia, MTHFR Gene Mutation, deafness on right side, and Protein S deficient. Patient also has PTSD which contributed to depression, anxiety, and binge eating. Patient also complained of tiredness and being lethargic for 4-5 years and was put on Zoloft for depression. Patient is allergic to nickel and aloe vera. Patient is also at risk for breast cancer due to family history. Patient’s medications are Sertraline, Oxybutynin, Magnesium, Vitamin D, Vitamin E, Iron, and Vitamin B.
My client is Margie M, a 69-year-old widower with chronic venous stasis ulcers. PMH: Asthma, Cataracts, Arthritis, Tremors, Narcolepsy, Congestive Heart Failure, Diabetes Mellitus, Peripheral Vascular Disease, Hyperlipidemia, Hypothyroidism, Gastric Ulcers, Irritable Bowel Syndrome, Micro colitis, Restless Leg Syndrome, Hypertension, Atrial Fibrillation, Anxiety, Depression, Cardiac Stents, and Cerebral Aneurysm. She lives in a two bed, one bathroom house with her daughter Becky, Becky’s husband Jim, and her twenty-five year old grandson Jason. Margie’s daughter, Terri, Jason’s mother is deceased. Jason has mild developmental delays. Margie has one son, Buster, who is not involved in her care. We met for lunch at McDonald’s
L.V. is a 51-year-old Hispanic female. She is 5’4 height and 150 lbs. Patient denies pain, discomfort, or chest pain during physical assessment. Patient is allergic to Aspirin she states that she gets rashes when she takes it. She was diagnosed with thyroid cancer 5 years ago and got her thyroid glands surgically removed. Patient denies the use of tobacco and drinks 2-3 beers on special occasions. Patient works for an American Restaurant as a server, she’s been serving for over ten years. Patient states that she’ll be getting her first colonoscopy next month and she just recently got her yearly mammogram done and results were normal. Immunizations are up to date and she gets the flu shot every year. Patient has four daughters and has been happily married for 20 years. Patient denies using glasses or contacts she visits her optometrist every year and has never had a problem with her vision.
The patient is an 88-year-old gentleman who is brought to St. Joe's ER complaining of inability to walk. The patient 6 days ago began to having trouble walking with his walker. He reported left arm pain which radiated up his left arm. The patient had pain in the left foot. The patient was taken to St. Joseph's Hospital in Wayne. In the ER he was diagnosed with gout and begun on Colchicine. Since that time he has shown no improvement. He has become essentially chair-bound and unable to walk so he is brought to St. Joe's ER. His medical history is significant for atrial fibrillation, hypertension, hyperlipidemia, coronary artery disease and the patient also has a colostomy bag he had a procedure done and they were unable to connect is
Susan is a 78 year old widowed lady who was admitted to a medical ward following an episode of coffee brown vomiting and breathlessness. Susan has a past medical history of chronic