Essay on History and Physical Examination Case 4

HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42-year-old gentleman from Bangladesh who presents with chest tightness, shortness of breath, and tachycardia. Dr. J.K. McClain of cardiology is evaluating his heart condition. The patient has had the recent onset of hemoptysis. He was treated for tuberculosis in Bangladesh 15

HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately 2 weeks ago she developed a respiratory infection, for which she received antibiotics, and completed that course of antibiotics. She developed some ulcerations of her mouth and was instructed to

31 y/o AA male patient seen today for psychiatric-mental health assessment. He is awake, alert and oriented x4. He is calm, cooperative and follows commands during assessment. The patient reports he is depressed, difficulty sleeping and nightmares at night. The patient explained his depression is as a result of deep thinking from a news he received two days ago from his elder brother that his mother is ill. Stressors identified by the patient include losing his job a week ago before the news about his mother; his wife is 6-months pregnant with their first child, who currently works part-time at her present job; patient relates difficulty paying monthly bills and inability to provide adequately for his family as a man. The patient denies mood swings, suicidal/homicidal thoughts and ideation. Patient reports his spouse is at work at the moment and he does not want to put stress on his wife due to her current condition. Patient denies been hospitalized for depression or psychiatric illness; and denies family history of mental illness. Patient reports he is seeking help because he does not like feeling this way using terms of “helpless and loss of worth from his spouse”. Patient reports he needs help with his depression and nightmares before his current condition get out of hands and ruined his marriage.

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

The patient complained of right lower quadrant pain and of feeling faint. Dr. O'Donnel documented a chief complaint, a brief history of present illness, and a systemic review of the gastrointestinal system and respiratory system. Dr. O'Donnel also documented a complete examination of all body systems, which included all required elements. Medical decision making was of moderate complexity.

The attending physician must refer the patient to a consulting physician to confirm the diagnosis and prognosis, while also determining whether the person is capable for making health care decisions. If either physician suspects the patient may be suffering from a psychiatric or psychological disorder that could impair judgement, the individual must be referred

HISTORY AND PHYSICAL EXAMINATION_______________________ Patient Name: Chapman Robert Kinsey Patient ID: 110589 Room No.: 322-B Date of Admission: 23 February ---Admitting Physician: Martha C. Eaton, MD, Geriatrics Chief Complaint: Admitted from Dr. Max Hirsch’s office due to deep ulcer on left toe. Admitting Diagnoses 1. Severe peripheral vascular disease, status post deep ulcer on left toe. Rule out thrombolysis. The patient was admitted to a regular floor. Condition is serious. 2. ALLERGY TO PENICILLIN, which puts patient into anaphylactic shock. 3. Continue with home medications. DETAILS OF PRESENT ILLNESS: Mr. Kinsey is an 87-year-old white gentleman with history of (1) Chronic atrial fibrillation, on Coumadin. (2) Chronic deafness,

No scalp lesions. Dry eyes with conjunctival injection. Mild exophthalmos. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosions of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her hard and soft palette. She has difficulty opening her mouth because of pain. Tonsils not enlarged. No visible exudate. SKIN: She has some mild ecchymosis on her skin and some erythema, she has some patches but no obvious skin breakdown. She had some fissuring in the buttocks crease. PULMONARY: Clear to precussion and auscultation, bilaterally. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Soft, non-tender, protuberant, no organomegaly, and positive bowel sounds. NORALOGIC EXAME: Cranial nerves ii – xii are grossly intact, diffuse hyporeflexia. MUSCULAR SKELETAL: Erosive destructive changes in elbows, wrist, and hands consistent with rheumatoid arthritis. Has had bilateral total knee replacements with stovepipe legs and perimalledal pitting edema 1+. I feel no pulse distally in either leg. PHYCIATRIC: Patient is a little anxious about these new symptoms and there significance. We discussed her situation and I offered her psychiatric services, she refused for now.

The practice of medicine has been shaped through the years by advances in the area of diagnostic procedures. Many of these advances were made possible by scientific breakthroughs made before the 20th century. Modern medicine arguably emerged. Both normal and abnormal functions (physiology and pathology) were increasingly understood within smaller units, first the tissues and then the cells. Microscopy also played a key role in the development of bacteriology. Physicians started to use stethoscope as an aid in diagnosing certain diseases and conditions. New ways of diagnosing disease were developed, and surgery emerged as an important branch of medicine. Above all, a combination of science and technology underpinned medical knowledge and

The patient tells me she noticed a rash on her of right side of her rear end approximately two to three days ago. She said she first felt a sensation before the rash started and then noticed that there were some squishy bumps there. She said it is tender if she touches it. If she is not sitting on it or lying on it or touching it is typically not tender. She has been trying not to scratch it. It does not tend to be itchy. She has been applying a diaper rash cream, but she is not sure if it is helpful or not. She says that she has had this in the past. She recalls having her first episode approximately two years ago and since then has in total, including this episode, had approximately four of them. She has not sought treatment for it before, but as this seems to seems to be continuing, she thought she should come in to have it evaluated. She is otherwise feeling perfectly fine. No fevers, chills, or body aches. No nausea, vomiting, or diarrhea. She is eating and drinking normally. She does not have a history of cold sores. She does not have any other unusual skin rashes. She does not have anything similar to this elsewhere on her body. She is currently not sexually active, does not believe that she is at risk for any such illness.

Individuals experiencing symptoms of psychosis may find it helpful to seek treatment from a mental

The patient must pay close attention to signs and symptoms in this stage. Signs may

The patient stated that he began experiencing painful swelling in his right knee over a decade ago. A large mass grew around the knee and he underwent a total knee arthroplasty. Not long after the arthroplasty of his right knee, he began experiencing similar symptoms in his left knee and right elbow.

The call centre of the Eastern Medical Faculty Foundation, hereafter referred to as EMFF, provides a competitive advantage to the Internal Medicine Department of the Chicago School of Medicine through the delivery of efficient and high quality service to patients. Treating patients generates revenue the Internal Medicine Department and contributes to investments in research in the highly competitive healthcare sector. Unfortunately, declining customer satisfaction, as evidenced in a growing number of customer complaints, suggests the quality of service is deteriorating and threatens the very competitive advantage of the EMFF.

Nose: Nares patent without any obstruction. No frontal or maxillary tenderness during palpation of the sinus cavities.