History and Physical Examination for Putul Barua Essay

A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he

Peripheral pulses posterior tibial and dorsalis pedis 2+ bilaterally. No edema on legs. Apical pulse regular rate and rhythm; s1, s2 noted. No murmurs, rubs or gallop rhythms. Denies dizziness, and fainting. Resp RR between 36-40 SpO2 85% per oximetry on 2 liters oxygen by n/c. Difficulty breathing and complaints of chest tightness. Patient unable to lay flat. Lung sound bilateral wheezes and crackles in right lower lobe. All other lobes clear A&P. Cough with yellow sputum. Tachypnea. Head of bed 45 degree. GI Last bowel movement 2 days ago, hard, long brown stool. Complains of constipation related to medication. Bowel sound are WNL in all 4 quadrants. Abdomen is soft, with no palpable masses. Poor appetite. Like sweet foods. Does not like vegetable or fruits. Like sodas, beer, scotch. Little water intake. GU Urinates every 2-3 hours. Yellow. No odor of urine. No history of UTI. One vaginal infection 2 years ago. No abnormal periods, last menstrual period 3 weeks ago. No pain or discharge. Skin Hair poorly groomed, dirty and oily. Nail are dirty and appear to be bitten. Skin clammy and moist with flushed color. IV IV of D5W at 125 mL in left forearm with 18

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

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.

Pulse rate is at 72. The blood pressure was 140 / 95,which is suggestive of high blood pressure and related to his medical history. No heart murmur was noted, and no other abnormalities were noted.

The general health of the patient is currently being compromised due to present illness mentioned above, but is stable. L.H. reports his usual health to be, “normal and not too crazy like this”. Patient has some fatigue noted while conducting daily activities; No recent weight change, fever or sweat. The skin noted to some discoloration on upper right side of back. There is no pruritus, rash or lesions present. Bruises noted bilateral on arms. Patient reported taking baby aspirin as daily medication. His hair is greying and thinning with no hair loss.

The physician was notified of the pain and discomfort related to the chest tube, which pain medication was given. Other notifications were the amount of drainage from both the chest tube and the JP. Both were under normal limits. SOB and fatigue with activities were also notified to the

Mr Brown is a 76 year old male, which presented to the emergency department via ambulance with thoracic back pain, which commenced two days prior to the presentation. The triage assessment stated the patient is alert, orientated, distressed, chest clear and equal, neurovascular intact with equal strength in all extremities and good strong regular pulses. The nil injury stated patient said he ‘just woke up with it’. The patient’s observation displayed a temperature of 36.9°C, blood pressure of 169/105, pulse rate of 99 beats per minute, respiratory rate of 20 breaths per minute, Glasgow coma score of 15, and a blood glucose level of 5.4. Mr Brown’s has a past medical history of atrial fibrillation, asthma, emphysema, hypertension, chronic back pain, lumbar fusion (L1), total

Musculoskeletal- erosive destructive changes in the elbows, wrist, and hands consistent with rheumatoid arthritis, has bilateral total knee replacements with stovepipe legs and perimalleolar pitting edema 1+. I feel no pluses distally in either leg.

On January, 31st, Patient F.F. arrived to the emergency room in the hospital with her brother due to an increased temperature for ‘the past 3 days,’ fatigue, and was ‘unable to catch [her] breath.’ A focused assessment revealed crackles and wheezes in the lower lobes of the lungs. The patient was leaning over in a tripod position and breathing heavily between words. The patient’s heart sounds were normal with a regular S1 and S2. The patient denied having chest pain and edema was not present. The patient reported having a productive cough with green sputum for the past 3 days. Vital signs were taken and the patient’s oxygen saturation was 88%. The doctor ordered 2 liters of oxygen by nasal cannula for the patient with a continuous

General—the patient reports lethargy, decreased appetite, and recent bloating; he relates that his pants are tighter in the waist than usual

A: Janie is a 60 year old Female with PMH of A-Fib, COPD, Hypothyroidism, HTN, Lung Cancer and recently diagnosed Pulmonary Embolism. Janie presents to ER for evaluation on SOB, cough with greenish sputum, sore thoart, hoarseness and generalized weakness. Janie lives at home with her husband, use to smoke ½ pack per week, but quit many years ago, denies alcohol or drugs. Family history is non-contributory. Allergies: NKDA. Differential diagnosis includes worsening Lung Ca, PE, COPD and CHF. Janie uses home O2 at 4 L/NC. V/S: T=98.7, HR=89, R=16, B/P=132/56, O2 sats=100% on 4L/NC, Pain=6/10. Labs: WBC=7.6, H&H=8.5/27, Na=141, Troponin=0.08/0.06, BNP=495, INR=4.2, UA=3+ protein, 1+ blood and 6-10 RBC. CXR: Impression:1). COPD with nonspecific coarsening of the basilar interstitium. 2). Mild cardiomegaly with borderline cardiac compensation. 3). Right

Patient is a 45 yo male; 5’7”, 221 lbs who entered the emergency room at 6:30 am on 9/7/14 with severe chest pain (onset at 6:00 am) radiating to his arm, L arm numbness and nausea and vomiting. Past medical history reported by wife includes peptic ulcer, tobacco use (1-2ppd for 27 years), elevated blood pressure (controlled by lopressor). Wife did not know of any family history but reports patient’s father is deceased, died at 42 in his sleep. Mother alive and with high blood pressure.

The patient is a 70-year-old gentleman who presents to the ED complaining of productive cough with yellow sputum over the past 2-3 days gradually getting worse associated with shortness of breath and some subjective fevers aggravated on exertion with no definitely relieving factors. The patient is known to be Losartan and Simvastatin. There is a question of a diabetes history. The patient presents with no white count, afebrile. The chest x-ray report is not available at the time of this dictation. However, the patient is described as being in some mild respiratory distress with wheezing over the entire lung fields. The patient is started on respiratory treatments, as well as intravenous is in the ED and placed acutely inpatient in the