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HIPAA Case Studies

Decent Essays

The patient, Jane Doe (pseudonym to protect patient’s privacy under HIPAA), was admitted to the hospital on May 1st for bilateral lower extremity pain. She was diagnosed with lower extremity cellulitis, a bacterial skin infection. Though the infection was in her legs and she reported pain, she could ambulate with her cane. Her background showed that she has a history of hypertension, peripheral vascular disease that led to chronic venous stasis ulcer, and obesity. She had no known drug allergies, and was full code (full resuscitation). Her progression of hospitalization showed that she had increased swelling in leg, could not tolerate ultrasound to her legs, started on vancomycin (antibiotic), and was scheduled for biopsy on her right leg. She …show more content…

Her goal was to mollify her right leg pain, since the cause for her condition was unknown. Upon assessment, I found that both her lower legs had +1 edema, were red, skin was a bit peeling, and warm to touch. She reported a bit of tenderness on palpation. The right leg, however, had black “scabs” towards the outer side; upon palpation, I noticed that they were under the skin and I could not feel any bumps. Other than her lower legs, her skin was dry and intact, color consistent with her ethnicity, no surgical incisions, and mucous membranes were pink, moist, and intact. She had a #22 IV in her left hand, and the IV site was clean. She was oriented x3, calm and cooperative, had clear speech, had no weakness, no flaccid tone, and no numbness. Her strength was normal in upper extremity, and her lower extremities moved against resistance. Her pupils were round, equal in size, and reactive to light. Her blood pressure was 133/76, heart rate 94, oxygen saturation of 98% on room air, respiratory rate of 18, oral temperature of 36.7

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