A visit note from Renu Mehta, MD (Family Medicine), dated 08/02/2017, indicated that the claimant presented with complaints of lower extremity pain and stomach pain. She continued to have abdominal discomfort. She had a history of hematuria and continued to have a 1+ blood. Objective findings showed a BMI of 31.89 with a blood pressure of 105/72. She was diagnosed with an abdominal pain and hematuria. A series of laboratory tests were recommended.
The patient is a 45 year old man who had GI surgery 4 days ago. He is NPO, has a nasogastric tube, and IV fluids of D51/2saline at 100 mL/hr. The nursing physical assessment includes the following: alert and oriented; fine crackles; capillary refill within normal limits; moving all extremities, complaining of abdominal pain, muscle aches, and "cottony" mouth; dry mucous membranes, bowel sounds hypoactive, last BM four days ago; skin turgor is poor; 200 mL of dark green substance has drained from NG tube in last 3 hours. Voiding dark amber urine without difficulty. Intake for last 24 hours is 2500mL. Output is 2000mL including urine and NG drainage. Febrile and diaphoretic; BP 130/80; pulse 88; urine specific gravity 1.035; serum
The patient is a 97-year-old female who presents to the ED because of urinary incontinence with hematuria and vaginal bleeding. The patient is very weak, unable to walk prior to admission despite her 97 years of age she is able to ambulate her home with the assistance for walker. In the ED she was found to be positive for influenza. The rest of her medical history she is chronic kidney disease, increased lipids, she is anemic and has hypertension. Urologic consultation indicates that catheterization of her urine in the ED showed it to be amber. Besides having influenza she probably is having vaginal bleeding. I believe that this patient warrants acute inpatient hospitalization. She is 97 years of age with a multiplicity of comorbidities
This is 35 year old WM. Patient was seen at UAB ED for UTI and kidney stone on 3/30/2016. Patient was discharged with roboxin and ibuprofen. Patient has a history of Hep C, was told about 12 years ago, and was retested at UAB and HVC was positive. Patient is a current resident at the Villige. Patient has a history of substance abuse, denies current use, last use about 10 days ago. Patient is a current tobacco user, denies use of alcohol or illicit drugs. Patient reports some depressive moods, denies thoughts of suicide or
This is a 68-year-old gentleman who presents to the ED stating that his legs are really swollen and draining yellow stuff. It is to be noted this patient was originally placed in observation status by the attending physician. After my clinical review of the chart and discussion with him I believe this patient warrants acute inpatient hospitalization. In the ED on presentation he is found to be anemic with a hemoglobin of 8.9, hematocrit of 27.1. He is also dehydrated with specific gravity urine greater than 1030. He has a low-grade temp of 99. On his physical exam he is noted to have a 2+ bilaterally pedal edema from his feet up to his knees, as well as chronic bilateral stasis changes in his legs with erythema and increased warmth.
Data: 51 yo M with a PMH of LAR on 07/31/2017 for a locally advanced rectal cancer. His postoperative course has been complicated by an anastomotic leak requiring multiple readmissions and drain placements by interventional radiology. He represented to VCU on 9/22/2017 with active GI bleeding. He was admitted to the STICU for resuscitation and given multiple units of pRBCs. He was embolized, stabilized, and transferred to the floor on hospital day 2. He continues to have dark blood in his stool, which was likely old blood. Urology was consulted for help managing indwelling foley, and recommend discharge with Foley (patient has hydronephrosis). Data: VS HR 77, BP 132/84, RR 16. spO2 94, T 37, pain 0.
The patient is a 99-year-old female who presented to the ED because the family found her more combative and fighting. She is known to have underlying dementia. In the emergency room she was found to have a urinary tract infection, started on IV antibiotics and was admitted. Her medical history is known to be blind in the right eye secondary to a history of macular degeneration, some degree of dementia, recurrent UTIs and history of paroxysmal atrial fibrillation. Workup done in the ED CT of the head revealed that she had extensive white matter ischemic changes and atrophy no acute intracranial events. She was mildly hyponatremic at 131. Hemoglobin was stable. She did not have a white count. My clinical review of this chart is that
Mr. B is planning on obtaining an associate degree in nursing. It is possible for him to achieve his ambition. Although schizophrenic, Mr. B has been able to manage his condition relapse-free for the last ten years. For the previous five years, Mr. B has been successfully working as a certified nursing assistant. The above information builds confidence in support of Mr. B because he has been meticulous with his medication regimen and with his psychosocial therapies. Since Mr. B has been able to manage his manifestations successfully, he should consider College for his associate degree. The only pre-condition to Mr. B pursuing his career plans is that he continues with his medication rigorously. Specific issues Mr. B may face while working toward
The patient is an 80-year-old female who is brought to the ED referred from the hemodialysis unit because they discovered a history of a fall from an upright position 2 days prior to her presentation. There is no further history available except from her sister who noted fall when the patient was tryng to to get some water. There was evidently no loss consciousness or seizure activity. The patient has severe underlying dementia cannot provide additional history. Her medical history is significant for diabetes mellitus, hypertension, end-stage renal disease, she has had previous TIA, anemia and peripheral arterial disease. Initial lab work up reveals her to be anemic with a hemoglobin 8.9, hematocrit 20.4, hyponatremic with a sodium 130, chloride of 89, and albumin of
The patient is an 80-year-old African American female unremarkable who presents to the ED complaining of inability to walk and loss of weight. She was sent in by her primary doctor, Dr. Nil. She also presents with some altered mental status. On presentation in the ED the patient is found to have a white count of 21,000, hemoglobin of 8.7, close follow up revealed a white count of 15.4 and hemoglobin dropped to 7.6. She has a left shift in her leukocytes and her platelets are increased. She is also noted to have iron deficiency anemia, acute kidney injury, as well as moderate to severe right-sided hydronephrosis with no clear explanation. Her urine culture is growing e coli with a fairly benign susceptibility pattern. However in view
Patient with complaints of edema into both of his lower legs and ankles. States this came about two days ago. Prior to that 2-3 days before that he states he had a little bit of flank pain on his left side. States he drank a lot a water that day and then it resolved and has not had it since, so here he is today. As far as medications, he is on no medications.
The patient is an elderly female 84 years of age was transferred to the ED from the primary care doctor's office because of increased confusion as well as increasing frequency of falls. There is a feeling the patient has a urinary tract infection. In the past the patient is known to have ESBL with proteus in the urine. She is growing Proteus again. On this admission the sensitivities are not yet available. she is also having frequent increased falls at home. There is also some suggestion that she might have had a syncopal episode. Her medical history is significant for hypertension, hypothyroidism, dementia, chronic osteomyelitis, she does have a pacemaker in place and as previously stated, and the urine is ready growing proteus within
CASE: 51-years-old male visiting from Guyana with past medical history of hypertension and hyperlipidemia presented with non-obstructive jaundice for 3 weeks. Patient is a former heavy alcohol drinker (15 years), and a former cigarette smoker (15 years). Patient was prescribed INH for latent TB 2 months ago. Also, 7 days prior to admission he was prescribed Gemfibrozil 600mg. Other home medications were Metformin 500mg, Ramipril 5mg, Metoprolol 50mg, and multivitamins. Patient denies Hepatitis A and B vaccination, blood transfusion, family history of liver cancer/chronic disease, drug use, recent sexual activity/STDs. Physical exam remarkable only for scleral icterus, jaundice and bright yellow urine and clay colored stools. Labs revealed AST 1626 ans ALT 1250, trending up form 2 months ago