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)
CASE SUMMARY: Officers responded to North Scott Hall to investigate the report of a 19 year old male UW Oshkosh student checking in with an odor of marijuana on him. The male admitted to smoking marijuana and drinking alcoholic beverages. He was warned for Use of Marijuana and cited for Underage Consumption of Alcoholic Beverages (2nd offense).
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.
Hello, On Tuesday (October 11th), we are requesting Council‘s approval of a resolution authorizing the purchase of 1750 Grant Street (APN: 224-02-022).
David Peterson will likely not be held liable for the actions of his son. Courts have determined that a person should not be held liable when an event is not reasonably anticipated. In Smith v. Allen, a child, age eleven, injured the plaintiff, age nine, while swinging a golf club that was left in the backyard by his father. The plaintiff claimed that the father was negligent and liable due to knowing the club was left outside, that his child would play with it, there was no warning against using the club, and improper use could lead to injury. The father demurred claiming the complaint was not sufficient. This demurrer was later sustained as the court held that the action was “not reasonably to be anticipated at all” making the father not
He reported that he had a cardiac cath done at Tampa General Hospital this year with no intervention. He has had a history of hypertension since the age of 19. He was not adherent to medications, but for the last three years, he has been adherent to all his medical care. No history of stroke or peripheral vascular
The patient, Jane Doe (pseudonym to protect patient’s privacy under HIPAA), was admitted to the hospital on May 1st for bilateral lower extremity pain. She was diagnosed with lower extremity cellulitis, a bacterial skin infection. Though the infection was in her legs and she reported pain, she could ambulate with her cane. Her background showed that she has a history of hypertension, peripheral vascular disease that led to chronic venous stasis ulcer, and obesity. She had no known drug allergies, and was full code (full resuscitation). Her progression of hospitalization showed that she had increased swelling in leg, could not tolerate ultrasound to her legs, started on vancomycin (antibiotic), and was scheduled for biopsy on her right leg. She
On Tuesday August 30, 2016 a Male 63 years of age came into Christus Spohn South Heath Center with a diagnostic order for chest and rib x-rays. He was being seen because of chest pain on his right side due to a fall. He had an extensive patient
1. The patient, Ms. Wanda Johnson was treated Humana Hospital now Glen of Virginia for six weeks before
The patient is an 86-year-old female who was brought to the emergency room because of bilateral leg swelling. She was recently discharged from the Arbor Glen Reha and she's developed increasing bilateral leg edema. Her medical history is significant for hypothyroidism, chronic kidney disease stage II, anemia which is a chronic, ulcer in the sacral ulcer stage III and she denies any other symptoms. Review of the lab work does show a bump in her creatinine from 1.27 baseline in February of 18 to 1.54 on this admission with an increase in her BUN. She also demonstrates a mild anemia of 10 with a MCV of 90. Her edema is described as massive by the attending physician. PT examination reveals she needs significant assistance to moneuver her
In the past years Jackson have dealt with major decrease in profit, decrease in patient services and more. However, Jackson Memorial was able to keep a positive net income because of its non-operating revenue. Both income statement and balance sheets are analyzed and compared with Jackson’ competitors to show some
The patient is a 61-year old female who has a history of Chronic Obstructive PulmonaryDisease (COPD), hypertension, Coronary Artery Disease (CAD), and anxiety. The patient is familiar with the diagnosis and illnesses that have been contracted over the years and is knowledgeable about the disease processes, medications, and signs and
Nursing Care Plan CLIENT CLINICAL PICTURE Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x
Case Study 1 – MI/ACS (Acute coronary syndrome) Ryan Rindlisbacher and Danielle Gossett 1/14/15 Assignment finished below following case information 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.