Cough And Reflux Case Study

According to the provider, the claimant's cough has been improved. His review of systems was positive for fatigue, malaise, sleep difficulty, shortness of breath, wheezes, and a cough. His blood pressure was 115/71 mmHg and his BMI was 30.35 kg/m2. The physical examination revealed wheezes. Clonazepam was prescribed for agitation. Atorvastatin, Nystatin, Citalopram, and a probiotic were prescribed. Continued use of Aspirin and a regular inhaler were suggested. Further, a follow-up visit with Endocrinology, Cardiology, and Pulmonology. As it relates to a spot in his lung, a repeat CT scan was recommended. The bronchial washes were negative for

S- 3671 dispatched to a m pt C/O of abdominal pain and black stool. Pt is a 49 y/o m whose C/C is abdominal and lower back pain. Pt also states that he is experiencing cramping around his left ribcage. Pt states that he has been experiencing N/V/D for the past four days. Pt also states that his bm's have produced black, watery stool since the monday prior to the incident date. Pt is able to provide EMS personnel with a detailed medical Hx that includes HIV, acid reflux, and recently diagnosed COPD. Pt also states that he recently stopped smoking cigarettes. Pt is also able to provide EMS personnel with a list of medications that he is currently taking that includes Duloxetine, Stribild, Ranitidine, Aripiprazole, oxycodone, and proair. Pt states that he has not taken any of his prescribed medications for the past four days prior to the incident date. Pt states that he has allergies to Kaletra and gabapentin. Pt states that his primary

Name: Margaret Elliot DOB: 1/22/65 Sex: Female Date: 1/22/65 CC: “severe shortness of breath” HPI: Margaret Elliot is a 52-year-old Caucasian female that is presenting with shortness of breath that has recently worsen. Mrs. Elliot states that her problems began 20 years ago when she had bronchitis, which she consistently has 2-3 times a year. She said that her symptoms have been getting worse the last 2.5 month, but have severely worsen over the past three days. She states that it has been restricting her daily activities and has been troubling her while sleeping lying down. She states that her symptoms improve alittle when she takes her medications. She also states that her symptoms worsen when she tries to walk across the room

CC Marcy is a 34-year-old female here today with her daughter for a followup regarding her chest pain and GERD. The patient tells me following her last evaluation on July 1st, she did take the Nexium as was recommended. She was taking 40 mg for about a month. She said that worked very well. Her symptoms lessened and ultimately resolved. However, when she ran out of the Nexium, the symptoms are back again. She feels a pain in the lower sternum area, as well as in the upper epigastric area and was relieved when it went away with the Nexium. She has not continued to take it and wonders what she should do next. She is eating and drinking normally. She did try to cut back on dairy as she initially thought that might be related, but found that was not the case and now has that back in her diet. She is up three pounds since I last saw her and is at her highest weight that I have in the office. She is having no nausea, no vomiting. No early satiety. There is no diarrhea. No constipation. No blood in the stool. No melena. She wonders what the next step should be. She does tell me that when she was talking with her family, her mother has had an ulcer and her sister has been diagnosed with "stress ulcers" in the past.

CC Follow up diabetes, hypertension, hypomagnesemia, renal insufficiency. S The patient is a 75-year-old female who did see a new pulmonologist (Daniel Kim, DO) as Elvira Aguila, MD left this area. She did have a CT scan done of her lungs. She was told to hold her metformin and had blood work done because of IV contrast. Her creatinine did go up to a high of 1.5, but then on repeat came back to 1.37 with a BUN of 14. I did have her decrease her dose of metformin from 1000 mg b.i.d. to 500 mg b.i.d. She did have a BUN and creatinine done in December of 2014, which showed creatinine of 1.46, BUN of 35. Repeat in March of 2015 showed creatinine of 1.1 with a BUN of 49. The patient has also been found to have proteinuria with a urine microalbuminuria/creatinine

D.D has no known allergies and his current vital signs are 36.8F, 115 pulse, 25 RR, 102/77, 91% SpO2. His lab work is all normal except for elevated WBC and glucose. D.D is put on a morphine PCA pump (1.78mg every 2 hours) to help regulate his pain, metronidazole (1500mg once a day) and cefTRIAXone in dextrose (2000mg once a day) to help fight the infection, oxyCODONE (3.6mg every four

Background: ----- Clinic presents a black male 68 years old. Currently experiencing dyspnea and lethargy. For the past week he has been having a increase of difficulty breathing. Complains of alternating periods of sweating and chills. Other symptoms he has been experiencing is a productive cough with expectoration of thick yellow

This is 51 year old AAF. Patient is here complaining of several issues as listed. Patietn reports for the past several days she had increased SOB at rest, non-productive cough, adiouble wheezes. Patient denies chest pain, N/V/ D. Patient is a current tobacco user wit 20 pack year hisotyr. Denies

CC Eva is an 8-year-old female here today with her father and her sister with complaints of a cough HPI The patient has really been struggling lately with a habitual cough and she is currently being evaluated by multiple specialists. They actually have an appointment pending with Richard Morse, MD who

She also seemed to have a respiratory infection and possibly urinary infection and was treated with IV fluids and IV ceftriaxone. I have not received directives from the family being a nephew to do otherwise. She recovered significantly with the IV fluids and further with the antibiotics and now seems back to baseline if not better for the absence of these medications. She actually said today that she felt well, which was very unusual. She said she slept well last night and had a good breakfast. All are things that perhaps six weeks ago would have led to long complaints. There have been small wounds on her

The first step for a focused exam is a thorough history and physical that should include a detailed timeline of a cough, provoking and alleviating events, sick contacts, travel and any other possible sources for a cough (Goolsby & Grubbs, 2014). The extent of the diagnostic and assessments will be determined by how the patient presents with a cough and how disruptive the cough is for the patient. Auscultating lung sounds can help find the location, type, and severity of the potential source of a cough (Dains, Baumann & Scheibel, 2016). Examining the head, neck and check externally looking for changes in skin tone/color, jugular vein distention, lymph node status, rashes, hair changes, swallowing, symmetry, retraction of the chest wall,

A chronic cough could be for many reasons ranging from your common cold to either a viral or bacterial infection. A cough is considered to be chronic if it has been three or more weeks. We as medical assistants need to make sure that we do a thorough job asking questions to determine if there may be any other health issues. The more information we gather about the chief complaint the better prepared the physician will be during his or hers examination. A chronic cough could be just that however sometimes a chronic cough could indicate other health issues or infections and need to be treated.

According to Mosby, cancer is a neoplasm characterized by the uncontrolled growth of cells that tend to invade surrounding tissue and metastasize to distant body sites. Cancer prevalence over the past decade has surged tremendously. The focus of this case study is lung cancer. Lung cancer is the leading cause of

His chief complaint was lower left quadrant pain, vomiting, and frequent urination.The patient also admits to constipation, nausea, and a fever of 102.2. He admits to a 25 pound weight gain over the last few months. The patient was

CASE ONE CONTINUED: She returns in three weeks. Her chest X-ray was normal. Her symptoms are unchanged.