Immunosuppressive Therapy Case Summary

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.

PAST MEDICAL/SURGICAL HISTORY: As above. SOCIAL HISTORY: Status post heavy smoking, 50+-pack-year history. He quit 10 years ago. Status post alcohol abuse, quit 3 or 4 years ago. He lives by himself and no longer drives but has 2 daughters here in Miami who take him where he needs to go. FAMILY HISTORY: Patient’s wife died 14 years ago of COPD due to lifelong smoking. Brother has diabetes mellitus. Unremarkable family history otherwise. REVIEW OF SYSTEMS: No fever, no nausea, no vomiting. Patient has incontinence of bowel. No shortness of breath, no chest pain, no palpitations. PHYSICAL EXAMINATION: Well-developed, well-nourished white male who is alert and oriented x3. Wears bilateral hearing aids. Afebrile with blood pressure 130/70. NECK: No carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: S1, S2 normal. No murmur. No S3 or S4. ABDOMEN: Soft, nontender. No arterial bruits. No masses, no organomegaly. EXTREMITIES: No edema. No pulses present in the lower extremities. The right great toe is absent. The left great toe shows a 2 x 1 cm deep ulcer with redness around the toe with pus extruding. PLAN 1. Get consult with Dr. Beth Brian, Infectious Disease. 2. Follow up with Dr. Hirsch, Orthopedics. (Continued)

Review of the medical record indicates that he had a MVA in 1977 with C4-5 injury that resulted in him been a Quadriplegic. Due to his bedbound and immobility status he has had multiple pressure ulcers over the years that have resulted in hospital admission and rehab stays. Other medical history include, HTN, hyperlipidemia, Sacral pressure ulcer, Right hip pressure ulcer, Constipation, depression. Bilateral arm contractures, bladder cancer, prostate cancer, urostomy and colostomy, aspiration pneumonia, neuropathy and MRSA.

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

At today's visit he is awake, alert and oriented. He complains of generalized pain. He states “I have pain all over today, my head, my back, my feet" I have not felt good for the last few days”. He rates his pain as 6/10 in severity; he describes his pain as shooting pain in different places. His pain does

The patient is an 88-year-old gentleman who is brought to St. Joe's ER complaining of inability to walk. The patient 6 days ago began to having trouble walking with his walker. He reported left arm pain which radiated up his left arm. The patient had pain in the left foot. The patient was taken to St. Joseph's Hospital in Wayne. In the ER he was diagnosed with gout and begun on Colchicine. Since that time he has shown no improvement. He has become essentially chair-bound and unable to walk so he is brought to St. Joe's ER. His medical history is significant for atrial fibrillation, hypertension, hyperlipidemia, coronary artery disease and the patient also has a colostomy bag he had a procedure done and they were unable to connect is

This is an 82-year-old gentleman, who was referred from Dr. Gretchen Marsh’s office because the patient’s BUN and creatinine were high, as he has acute kidney injury. The patient went to Dr. Marsh’s office yesterday and was having generalized weakness. He does not have any vomiting. No diarrhea. No fever. No cough with expectoration. No sharpness. No wheezing. No headache. No dizziness. No passing out. No rectal bleeding. No hematemesis. No abdominal pain. No sore throat. No stuffy nose. No cough with expectoration. No burning, frequency, or

Mr. Garcia’s BP is 154/94, HR is 92, and respiratory rate is 20. The health care provider found him to have lightly bluish color to his lower extremity. The patient also had visible varicosities as well as 1+ edema that ends just above his ankles.

E.P. is an 88-year-old Caucasian male. He was admitted on 02/18/13. His code status is full code, and he declines to bring in his advanced directive. He reports that he is 68.5” tall, and his actual weight is 165 pounds. He and his wife are the sources of information, and they are reliable. His blood pressure is 124/62, taken on his right arm in a lying position, his oral temperature is 99.8, his right radial pulse is 74 beats per minute, his respiration rate is 16 breaths per minute and his pulse oximetry reading is 92 on room air. He is allergic to latex, cephalexin and sulfa drugs, with a reaction of hives, and to IV dye, with a reaction of moderate rash. He was

2. Also recommend getting dermatology referral to assess the lesion on his right forearm which has been nonhealing and indurated margins, is suspicious of malignancy or sarcoidosis

I.We have reason to believe that the system that is being attacked in Sam is his lymphatic system. There are many signs that point to this conclusion with the most strong point being his edema on his right leg. This Edema, or abnormal accumulation of fluid, is believed to have been caused by a compromised amount of function in the lymphatic system. This system’s primary function is to pick up and return leaked fluid from blood vessels. When this system can not function properly it could result in an edema and pain, both of which are being experienced by our patient. The next point that leads us to believe the lymphatic system is being attacked is the fact that there are signs of bacterial infections. The lymphatic system also plays an immunal role in helping the body function, and if it couldn’t produce the white blood cells needed to fight infections, bacteria could potentially take over, which could be the case with Samuel.

The patient is 79-year-old gentleman who is brought in by his family due to complaints of left sided facial droop over the past 7-10 days. He also complained of difficulty swallowing due to pocketing of food on the left side of his mouth. There are no complains of weakness, loss of consciousness or syncope. The patient is also complaining of incontinence occasionally. The patient admits to having difficulty ambulating secondary bilateral lower extremity pain and swelling. The patient was recently in the hospital from April 6 to April the 9th with hypertensive emergency which placed in congestive heart failure. He also has some hearing loss. It is noted that he is noncompliant with medications at home. He walks with a walker at baseline.

At today's visit he is found at Tiffany Hall SNF, he is awake and alert. He reports that he continue to suffers from edema in legs. He states the edema is chronic and constant, it has not improved and it has not worsened. He is furosemide but has not noticed any improvement in his edema. He denies pain, SOB. He generalized weakness and is getting physical therapy, he continue to be at risk for falls. He continues to need assistance with some ADLS. He is able to feel himself with meals

At today's visit he is accompanied by his wife. He is awake, alert and oriented times 3. He reports that he was started on Augmentin antibiotic for respiratory infection 2 days ago. He states that he has a cough that started a week ago, the cough is nonproductive, the cough is worse at night, he states that the coughing increases his pain. He states that he has not tried any medication for the cough but would like some thing. He complains of , chronic, nagging,

His background included history of chronic obstructive airway disease, hypertension, diabetes, Ischaemic heart disease(Coronary stenting 5 years ago) and hypothyroidism.