Jacquline Catanzaro: A Case Study

DIAGNOSTIC DATA: White count was 13.4, hemoglobin and hematocrit 15.4 and 45.8, platelets 206, with an 89% shift. Sodium 133, potassium 3.7, chloride 99, bicarb 24, BUN and creatinine are 18 and 1.1, respectively. Glucose 146, albumin 4.3, total bilirubin 1.7. The remainder of the LFTs is within normal limits. Urinalysis reveals trace ketones with 100mg per decilitre protein and a small amount of blood. CT scan was performed revealing evidence of acute appendicitis with pericecal inflammation, as well as, dilatation of the appendix and

PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.

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.

Susan is a 78 year old widowed lady who was admitted to a medical ward following an episode of coffee brown vomiting and breathlessness. Susan has a past medical history of chronic

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)

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.

Patient was in the ER room when first seen. PT was with her family members and family states that she speaks little English and that she has had abdominal pain for the past day along with bloody stools. Family states that she is on calcium supplements and no other medications. Last oral intake is 24 hours ago. Family states no known past medical history. Pt is in the hospital bed in the fetal position and towards the right side. Patient's airway is clear and breathing is normal. Skin is warm and dry. Patent is AAOx4. Assessment of head, neck, and chest show no signs of deformities. Abdominal area not assessed due to severe pain. Back is without deformity. The upper extremity shows no sign of deformities or trauma. The lower extremity shows

My patient is 79-year old, male that was brought the University of Kentucky medical center emergency department via ambulance on January 14, 2017. The patient was smoking while using home oxygen, when he fell asleep. The EMS responded to a home fire.

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.

Prior to my entrance into the patients’ room, I had to look up the patients chart to see what her current status and past Hx was. As I as reviewed my patients chart, I saw that she is a paraplegic who is paralyzed from the waste down with no smoking History or pulmonary dysfunction. My patient had been on SVN Pulmicort treatment

Chief Complaint: painful ulcers in oral mucosa and swelling/redness in his right hallux (“big toe”), weight loss, abdominal pain, initially was constipated but now passing stools regularly with no observable blood, elevated temperature, poor appetite, fatigue, skin lesions on right shin, painful sensations in jaw

On examination patient is neurological unstable, alert with confusion and slurred speech. Patient appears disheveled and have poor hygiene. Nasal cannula in place. Medications reconciliation was reviewed with Tomas. Tomas was unable to given medication doses and frequencies. Pervious medical records reviewed, show Tomas has been admitted at least 3 times in the last month but left against medical advice (AMA).

I performed a Head to toe assessment on her, my findings for the neuro assessment included her being awake alert and oriented to person only. Her pupils were equal, round, and reactive to light, with accommodation. She is wheelchair bound with +3 range of motion in her lower extremities and +5 in her upper extremities. She wears glasses, is hard of hearing and has difficulty swallowing. Her Cardiovascular assessment included normal capillary refill < 3 seconds. No JVD and No edema or swelling. Her apical pulse was 80 beats per minute. Mucous membrane was pink and moist. Her skin was warm dry and intact. She currently has no wounds or bruises.The respiratory assessment included clear and equal breath sounds. Respirations were 16 and unlabored. Chest explains symmetrical. No secretions/ sputum. GI: abdomen soft ad non-distended, last bowel movement was on September 20, 2016. Bowel sound present in all four quadrants. Her diet consists of a mechanical soft diet. GU: foley in place , draining clear yellow urine with no pain or discharge. Her