This 54 year ld AAM. Patient has a history o fDM, HTN, and hyperlipidemia. Patient's current medications are Glipizide 10 mg BID, ASA 81 mg QD, Triamtereine /HCTZ 75/50 mg, Pravastatin 40 mg QHS, and lorsatan 300 mg QD. Patient states he is taking all mthe medications as prescribed, and he thought he was doing fine. Patient states no one in the Federal Prison System had checked his A1C in several years. The patient's A1C today is greather than 14 %. Patient denies buller vision, headache, chest pain, SOB, N/V/D, or fever. The patient denies decreased sensation of his feet, increased thirst or urination. Patient denies any depressive moods. The patient is here with his wife and had a long disussion with the plan of care for his DM, HTN, and
hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min
S- 3671 dispatched to a m pt C/O of abdominal pain and black stool. Pt is a 49 y/o m whose C/C is abdominal and lower back pain. Pt also states that he is experiencing cramping around his left ribcage. Pt states that he has been experiencing N/V/D for the past four days. Pt also states that his bm's have produced black, watery stool since the monday prior to the incident date. Pt is able to provide EMS personnel with a detailed medical Hx that includes HIV, acid reflux, and recently diagnosed COPD. Pt also states that he recently stopped smoking cigarettes. Pt is also able to provide EMS personnel with a list of medications that he is currently taking that includes Duloxetine, Stribild, Ranitidine, Aripiprazole, oxycodone, and proair. Pt states that he has not taken any of his prescribed medications for the past four days prior to the incident date. Pt states that he has allergies to Kaletra and gabapentin. Pt states that his primary
Member experienced moderate pain due Dx. Osteoarthritis, have an unsteady gait, experiences dizziness (new medication Flomax 0.4 milligram) and is a risk of falling (score 11). He needs assistance of daily living. Goes to bathroom frequently due to Enlarged prostate.
The patient is an 85-year-old female who is brought to the ED by her family because of increasing confusion and supposedly she had a degree of altered mental status of two hours previous to presentation. In the ED she is completely worked up. CT shows advanced atrophy with microvascular changes and several lacunar infarcts nothing acute. Specific gravity in the urine reveals her to be markedly dehydrated. She culture completely, started on IV antibiotics, IV fluids and B12. On the day after admission she still presents as persistently confused. She is evaluated by PT. The patient who was formerly ambulating with a walker and allegedly driving a car is unable to be ambulated. Before the history indicates that she has a slow downward
This is 38 year old white female. Patient has several issue, chronic back pain, left eye blindness, leg neuraliga and numbness, insomnia, depression Hep B&C positive. Patient reports MVA 18 years ago, lost her mother and father and injured her back and lost her right eye sight. Patient has a history of chronic depression and night terror and she was taking seroquel. Patient has impaired hip joint immobility related injury and chronic pain. Patient reports she is depressed but denies thoughts of suicide or homicide. Patient states she has a history of iv drug use, and her sexual encounter are only with other females. Patient was diagnosed with Hep B &C and doesn't know what to do. Also it has been a long time since she had her eyes checked.
BH is a pleasant 62- year old male who has been treated at Daybreak since June, 2014. He has been treated for hypertension, gout, renal insufficiency, pre-diabetes, hyperlipidemia and elevated cholesterol. He has a history of alcohol abuse.
AA explained the case and its etiology Gc is 75 and had been in and out of the center many times never completed treatment at detox, AA as well highlighted that Gc will not be admitted again to the center
The patient was admitted to the hospital by her daughter after discovering that she had abandoned her medication and was significantly experiencing adverse effects from the withdrawal. The patients’ medical history included renal dysfunction, anemia, malnourishment, back pain, and a family history of mental health. The patient has a psychiatric history of being previously placed in the same clinical structure eight months ago due to related issues including the failure to take her medication and increased levels of mental health conditions that led
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.
Mr. Hightower is a 52 year old male with a PMH Type 2 DM, Hyperlipidemia, and HTN. He is a new patient to your office stating he stopped his meds several months ago and he cannot remember what he took in the past. His BP is 150/90. HR 88, RR 20 BMI 35. HGB A1C is 9.6, Total chol 225, LDLs 183, HDL 35. CBC, CHem, LFTs are wnl except for glucose of 124. Discuss the focused pertinent physical exam for this patient as well as what further diagnostics are needed in providing evidenced based care. What medications are important to start for this patient to treat his co-morbidities. Include the follow-up for this gentleman along with pertinent diagnostics needed at
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.
NH hospitalization record reveals a medical history of a non-injurious stroke, numerous episodes of sickle cell crisis, acute chest syndrome and chronic asthma. NH is prescribed a daily regimen of medications including a daily dose of 15,00 mg hydroxyurea, 1 mg folic acid for his SCD and 44 mcg of inhaled fluticasone for his asthma. Currently, while suffering from sickle cell crisis, NH is prescribed oxycodone 5mg, Toradol 21 mg IV solution, acetaminophen, and morphine as well as a continuous IV drip of D5 ½ NS, KCL. Due to the opioids and level of pain NH has endured the last 4 days (since beginning of crisis) he is exhausted and considered a fall risk due to his fatigue and reports that he naps off and on throughout the day and only gets out of bed to use the
This is 58 year old AAM. Patient reports he was told several times, by nurses at the health fairs, that he has HTN. Patient is here today to discuses and start on his BP meds. Patient reports intermittent headache at times and blurred vision, denies chest pain, SOB, N/V/ D, or fever. Patient is a current tobacco (1 pack/day) and alcohol user (1 -2 beers at bed time), denies use of illegal drugs.
“LBD is an umbrella term for two related diagnoses. LBD refers to both Parkinson’s disease dementia and dementia with Lewy bodies.” (Lewy Body Dementia Association 2015). According to Perry and Perry R.H (1995) Lewy body dementia is related to a disturbance in cholinergic transmission. Neocortical cholinergic deficits in this disorder are more extensive than in Alzheimers disease and are associated with symptoms that are commonly related to delirium, such as visual
This is 49 year old WM. Patient has a history of HTN and currently taking lisinopril 25 mg QD and HCTZ 25 mg 2 tabs QD. Patient's current BP 152/85. Patient denies chest pain,SOB, N/V/D, or fever. Patient also has wound to his right leg, chronic issue for the past 16 years. Patient had a gun shot would to the leg and had rod placed. It's got broken 16 years ago, ever since than he had chronic infectin at the site, at times he hasa to lenxit and drain the infection. Current pain