Client Complaints: The patient complained of crushing chest pain that radiated to his neck and jaw, short of breath (SOB) with exertion, and diaphoretic that had been going on for four hours that day. HPI (History of Present Illness): The patient major symptom of chest pain, accompanied by SOB and diaphoresis prompted him to seek help in the emergency room (ER). He had this similar symptoms that eased up with rest for the past six months. However, in the past four days the symptoms became severe and unbearable. The patient returns to the hospital for follow up visit regarding the stent placement and review of risk factors associated with angina. The patient is still apprehensive of experiencing another episode of angina. PMH (Past …show more content…
Social/Personal History (occupation, lifestyle—diet, exercise, substance use): The patient is a licensed carpenter and is the sole provider for his household. He lives with his wife in a small apartment in an inner city. He admits that he does not get involved in physical activities due to unsafe neighborhood with high crime rate. He has no hobbies and prefer to read at home. He eats one large meal a day after work, misses breakfast majority of the times. He admits eating unhealthy meals for lunch, few serving of fruits and vegetables, and high- calorie food mostly pasta and meat at home. He does not engage in any street drugs or alcohol intake, however he admits smoking cigarette one pack per day for the past thirty years. Description of Client’s Support System: The patient lack strong support system. He live with wife who is currently disabled with uncontrolled type 2 diabetes. Their three grown-up children live in a different area. He lacks community socialization due to majority of the population living at the poverty level and barely have emotional or social support since there are no relatives living in their city. Behavioral or Nonverbal Messages: The patient is the sole bread winner in the family and experiences some nervousness going back to work due to finances. His self-efficacy is disrupted as he is not sure if he is capable of caring for himself and his
Peter is a 47 year old male, with severe learning disabilities who lives in a community setting with other residents. He requires the assistance of his carers to meet his needs. Peter has asthma which is controlled by inhaled medication, he has a history of depression, he has a grade 2 pressure ulcer to his sacral area, and his body mass index (BMI) is 31. He is visited twice daily by the district nurses (DN)who administer Peter’s insulin, because he has been newly diagnosed with type 2 diabetes, following a recent hospital admission. Peter has also experienced complications with his diabetes as following his diagnosis; he has been admitted acutely into hospital twice following a hypoglycaemic episode.
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
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.
I spoke with the family and arranged for him to have video call his son so that he can see and talk to his granddaughter. This helped the patient’s willingness to participate in activities of daily living and reenergized him.
I will be using the patient initials (MK), throughout this paper when I reference her. I asked the patient a list of questions about her life and I will summarize the answers for you now. MK is an alert and oriented 84 year-old female who is happily married and lives with her husband of 56 years. MK is retired and worked as a high school secretary for 20 years in the town she lived in. She grew up in Pennsylvania with her parents and was the oldest of five children. Her family medical history includes cardiac disease and diabetes with all of her brothers and sisters still alive. MK has three of her own children who all live with in a 30 minute drive from her home and they speak frequently on the phone with her and her husband. MK and her husband are going on a vacation together this summer to South Carolina with her son and his family. MK still hosts holidays and family gatherings at her home with only a couple holidays hosted by her son at his home. MK and her husband receive social security and her husband’s pension as their income. They have Medicare and also a supplemental insurance through AARP. MK enjoys her exercise class, reading, her card club, traveling and is also very active in her church including being on the bereavement committee. MK still drives her own car around town to visit friends and shop but prefers not to drive at night
Patient is a high school counselor. He participates in physical activities by running 2 to 3 times a week, playing golf, and volunteering at a nursing home. The patient is married with one daughter and one son. He does not use tobacco and periodically drinks at
Patient L.H. is a 69-year-old married Caucasian male that is a retired teacher that lives at home with his
The physician was notified of the pain and discomfort related to the chest tube, which pain medication was given. Other notifications were the amount of drainage from both the chest tube and the JP. Both were under normal limits. SOB and fatigue with activities were also notified to the
S has quite a strong baseline of strengths. Firstly, Mrs. S is a very kind man, never lashing out during interviews, always receptive of health provider interventions even when he might not agree. In addition, he has completed his high school diploma. Mr. S is also good at maintaining and looking after his room at the booth, as evidenced by the recounts of the case manager’s room visit. In addition, Mr. S always attends his medical appointments, and IM injection appointments, and has good insight on their importance. The patient is also has insight to find help from the institute or ER if warning signs, or symptoms creep up. Mr. S is also responsible enough to call if he cannot make an appointment. In addition, he has good personal hygiene during his visits. Mr. S also has a number of deficits he has to combat. First of the deficits, include his ¬¬lack of social support; like previously mentioned about his parents, half-sister or half-brother. This can put Mr. S at risk for redevelopment of avolition and negative symptoms that have previously hindered his success, and will become deficits. Another deficit is his inability to manage his own finances and money, as he gets his welfare allowance every week from his case manager, and social worker, who also manages his finances. A third deficit might be his inability to get food. The final deficit, would be his situation with the Booth Center, as he might find himself to be homeless. Mr. S’ only resources are the case manager, the writer, social worker, and the FEPP
A possible barrier for Mr. B includes: Physical barriers, he is in the wheelchair due to broken pelvis related to the car accident and it is a big problem for Mr. B to find appropriate care such as therapist. Cultural barriers: patient has different culture, tradition, manners and norms. Cultural deference sometimes makes communication demanding, as the mindsets person varies from culture to culture. Psychological and emotional barriers, due to PTSD these barriers may affect the way he thinks about his health. He is experiencing irritability; trouble sleeping, eating disorder, depression and anxiety. Access to health care barriers, transportation is one of the major problems for Mr. to access the health cares and other important
Father is recovering, and now have more family support that can take on more of a lead role in assisting with providing care
The patient I have chosen to write about is a seventy year old male who has been married for nearly fifty years. He has two grown up sons, both married with
Chest pain is a very common symptom, and around 20% to 40% of the general population will experience chest pain in their lives(149). In the UK, up to 2 % of visits to a general practitioner are due to new onset chest pain (150). Approximately 5% of visits to the emergency department are due to a complaint of chest pain, and up to 40% of emergency hospital admissions are the result of chest pain(149, 151). Approximately 52,000 new cases of angina per year are diagnosed in men and 43,000 in women. The incidence of angina increases with age(123).
The Social Worker was contacted by Dr. Katoch’s MA to meet with the patient to assist with social services. The patient is a 57 year old, married, African American female who lives with her husband, daughter and two grandchildren. The patient was rambling and repetitive in her speech, she demonstrated limited spatial orientation, difficulty in thought process, some confusion and has experienced some memory loss as evident by inability to remember past events and work history. The patient was assisted by a cousin during her interview with the social worker and she facilitated most of the speaking. The patient’s cousin express concern that the family is experiencing difficulty due to poor financial management by the husband who handles all of
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.