Longitudinal Pain In The Emergency Room

SKIN: She has some mild ecchymosis on her skin, and some erythema. She has patches but no obvious skin breakdown. She has some fissuring in the buttocks crease. PULMONARY: Clear to percussion and auscultation bilaterally. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Soft, nontender, protuberant, no orgonomegaly, and positive bowel sounds. NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia. MUSCULOSKELETAL: Erosive, destructive changes in the elbows, wrists, and hands consistent with rheumatoid arthritis. Has bilateral total knee replacements with stovepipe legs, and perimalleolar pitting edema 1 +. I feel no pulses distally in either leg. PSYCHIATRIC: Patient is a little anxious about these new symptoms and their significance. We discussed her situation and I offered her psychologic services. She refused for now.

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.

The patient was referred for a new itchy and tender bilateral groin lesions that the patient says will drain pus. He also has multiple other complaints. He gives a history of being allergic to DOXYCYCLINE. As previously stated, he has tender sites which can drain pus off and on in his groin for years. There is also history of facial acne and scalp acne since his late teens. He took Accutane during his 20s with improvement by history. He flared and repeated Accutane about one year after completing the first course by his history. He is bathing with unscented Dove and uses cocoa butter lotion. He also has a second problem of itching over his back, shoulders, and arms, and legs

BB’s skin presents as pink, warm and dry. No obvious signs or symptoms of abnormal bruising or lesions present however, the patient states that the skin has of late has

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.

The working diagnosis is that this patient is suffering from Angioedema as a result of Anaphylaxis and developing Urticaria. Angioedema is the swelling of deep layers of the skin due the accumulation of fluid, symptoms of Angioedema include swelling of the eyes, lips, hands and feet.

PHYSICAL EXAMINATION: HEENT: Tympanic membranes and external auditory canals are within normal limits. Throat is clear with no gingival lesions. He is ______________. No obvious proliferate retinopoathy. NECK: No carotid bruit. No thyroid enlargement. LUNGS: Clear to auscultation. HEART: No S3, S4 or murmurs. ABDOMEN: Soft with no organomegaly. Normal bowel sounds. FEET: Good dorsalis and posterior tibial pulses bilaterally. Left foot has no abrasions, lesions, sores or ulcers. Right foot shows obvious deformity from previous break. He has an area located between his second and third metatarsal head that has clearly been an abscess that has broken through. He also has an obvious foot ulcer located over the instep of his right foot, full thickness. There is tracking to the broken foot, to which the ulcer area is connected and there is a question of osteomyelitis in this area.

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

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.

No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished. Although pain is a common experience among individuals 65 years of age and older, it is not a normal process of aging. Pain indicates pathology or injury. Pain should never be considered something to tolerate or accept in one's later years.

Mr. P, a 27-year-old African American man, was brought to the emergency department (ED) by his wife. The patient reported polyuria for the past three days, few episodes of vomiting prior to arrival and polydipsia. On assessment, the patient appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is very poor. He has deep, rapid respirations and there is an acetone smell to his breath. He is alert and oriented X 2 and is having trouble focusing on the questions.

The medical assistant should listen to the patient and try to make him as comfortable as possible, then ask questions such as; Why are you feeling this way? Are you in pain? Is there anything we can do to change how your feeling. The medical assistant should also inform the Dr. of all of this information.

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

L.F, age 91, diagnosed with hypertension, dementia, and hx of falls. The clients general skin pigmentation had no deviations or abnormals from normal skin color, expect for on the clients left buttock. The area on the buttock was red, but still blanchable. The skin was warm to palpate in all areas of body expect for her hands. The clients hands were cold to touch but no problems or complaints noted from the patient. Skin turgor tested on clients sternum and top of hand. Skin turgor was loose and returned to normal baseline within one second. The clients skin was soft to touch, with only small area of dryness located on the clients buttock. Client had many winkles all over body. There was no odor detected on client. Deodorant was used during