Hep B & T Case Summary

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.

Since I have last seen the patient, she tells me she has been to see [Mary Bluen at Orchard Park in Portsmouth.] She has been seeing her in counseling now for the last six to seven weeks and her next appointment is tomorrow. She says she has been struggling lately with her feelings. She established a relationship with a superior at work who is married and she herself is married. She says this is something that she is trying to work through to figure out why she is making these choices. Her plan is to ultimately end her marriage. She is not sure if she will continue to see this male at work again or not. She is just not sure what her choices are. She said on top of all of this, she just found out today that she has been given a 90 day noticed, so she is not sure if she will even be able to keep the same job and she is fairly certain that this is follow

Erin is a 33yo, G3 P1101, who was seen for an ultrasound evaluation and consultation. The patient has a longstanding past history of substance abuse as well as alcohol abuse and she is HIV positive with a positive viral load. She is followed by infectious disease and is on numerous medications including Genvoya and Prezista. She also is reportedly hepatitis C positive. She has a history of alcohol abuse in the past but states that she has not had any alcohol since early June. Her LMP was 08/06/17. She also has a history of cocaine usage but again denies any usage in the past year. She does have a longstanding history of physical abuse and has had issues with anxiety. She has 2 previous deliveries. The 1st of which was in 2004 that occurred

R.O. is a 43-year-old female Latino patient who has been living at home alone since she got divorced three months ago. She does not have any living or available family in the United States. She is the oldest of three children. Her parents died of an accident when she was little. Two of her sisters live in Mexico. She has lost contact with her family in Mexico when she got married and move to the United States. She also has stopped communicating with her ex husband since they got divorced. Although she does not have any support from her family, she states that her church member has been very supportive. Moreover, R.O. states she was a homemaker until the divorce. Currently, she has been working as a dishwasher near her house.

Client reported no known allergies to food or drugs. Client reported that she has 8 years daughter. Client indicated her physical health "average". Client reported that she does not have a current primary care physician at the time of assessment. Client reported that she is not currently pregnant and does not taking medication for medical purpose. Client denied any issues in this dimension. Indicated no current condition or medications that would interfere with treatment. Client exhibited adequate ability to tolerate and cope with physical discomfort. No immediate biomedical services are needed at the time of assessment.

Patient presented to the ED via EMS after a attempted suicide by driving his car into a tree. Patient reports braking up with his girlfriend a month ago and experiencing depressive symptoms. He reports that his girlfriend and him had a 7 year relationship, which he shared a with a 6 year old daughter from the relationship. Patient expresses that in the past he has been verbal aggressive towards her and she has recently moved into er mothers home. The patient reports since her leaving he has been having suicidal thought. He reports that he never attempted suicide, however has had a history of depression and a verbally abusive father. The patient express a poor appetite, sleep, and loss in usual pleasure, which is praying for change in his relationship.

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

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 for the

J.C., is a 41 year old female with a history of bipolar disease, who presented to the psychiatric department by EMS activated by shelter staff. She was brought in since she was presenting with manic behavior and psychotic thoughts. She currently lives in uptown Manhattan in an independent home but previously lived in a women’s shelter. She returned to the shelter, where she spoke words of retaliation and guns, and talked about her acquaintances at the shelter and her ex-husband however, she did not speak of any plan. The staff called EMS reporting this behavior and EMS then brought her to the hospital. On admission, she reported walking to and from Manhattan and the Bronx. She also has psychomotor agitation and has difficulty sitting down. She reports not taking her psychotic medication for the past 9 months. In addition, she reports no suicidal ideation, and has no history of violence. She also reports using substances such as marijuana, cocaine, and alcohol. She also smokes ¼ pack of cigarettes a day.

The following case scenario is based on a fictitious patient, and it would be use on this paper as a guidance to develop a patient and family teaching plan. The situation: Mrs. Marquez, a 39-year-old Caucasian female was admitted into the Emergency Department due to complains of shortness of breath and anxiety. Patient cannot take deep breaths, appears overweight and denies Allergies to medication. The background: Patient has medical history for panic attacks, atrial fibrillation, and Grand Mal seizures; however, patient is not constantly taking her seizure medication. Patient previously had a cholecystectomy, and smokes 1 pack of cigarettes per day for 12 years. The Assessment: Patient vital signs 98.8° F oral, 109 heart rate, 26 respiratory rate, 150/86 blood pressure, SaO2 97% on room air. Denies pain. Neurological; Patient is 65 inches tall, weighing 246 lbs. She is able to move all extremities with strong pushes and pulls. States her “last seizure was two months ago.” Respiratory; Respirations are even, deep, and rapid. Lungs are clear on auscultation. Cardiac; EKG reveals atrial fibrillation; patient states, “It feels like my heart is racing at times.” Pulses are palpable +3 all extremities; capillary refill is instant. GI; Abdomen soft, no distended, and no tender with bowel sounds present in all four quadrants; skin is intact and warm. Current medications: Dilantin 400mg PO BID, Lexapro 20mg PO daily, Metoprolol 25

This is 34 year old WF. Patient is a resident at the Lovelady Center. Patient stataes she had a baby 7 weeks ago. She is depressed and misses her bacy. She is to stay at the love lady for 90 days, but possibly for 9 to 12 months. The bay is well taking care of by her boyfriend (the baby's father). Patient denies thoughts of suicide or homicide. Wants to get through the program and get back to her baby. Patient denies chest pain, SOB, N/V/ D, or fever.

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 is 36 year old whte female. Patietn is complaining of severe earache 9/10. Patient reports she was seen at St.Vincent ED yeasterday, but didn't get treated and was told to take ibuprophen and flushout the ear with OTC. The patiet is tearful, and scared. Patietn also reports alll of her current Rx been out for past 2 weeks and haven't been taking any of her Rx. Patient denies chest pain, SOB, N.V/ D, or fever. Patient reports depressive moods, but denies thoughts of suicide or homicide.

This is 48 year old whte male. Patient is here complaing of bug bites, throughout his body, including between his fingers. He reports he is depressed becuase of this reason. Patient staes he cannot even sleep, because of severe itchness. Patient reports he is a current resident at Jimie Hale, and so many of residents are infected with bug bites. Patient also reports hitory of asthma and he is out of his albuterol HFA, and experiencing SOB at times. Patient also reports Acid reflulx, which is a chronic issue, but unable to get his medications because of his current situation, and lack of social support. Patient report's his current pain at

Social History: The patient widowed and lives in a house with her two daughters. Currently employed as a supervisor at Walmart and has health insurance through her work. Works full time and enjoy her work. She enjoys spending time with her family. She is sexually active. She is currently in an intimate relationship for the past one year after the death of her husband and used condoms occasionally when having sex. Highest level of education is bachelor’s degree