Medical Case Study 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.

The Board office received a letter from Mary Fahey, MPHP via fax on 05/04/2015, advising that Dr. John Medley, M.D. a current “ILOD” status had informed her that he had relapsed over the weekend of April 25-26, 2015.

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

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.

3:30 p.m.: Mr. B. arrives at triage accompanied by his son. Assessment results - B/P 120/80, HR-88 (regular), T-98.6, R-32, weight 175 pounds, pain 10/10, Left leg appears shortened with edema in the calf,

As a nurse executive leading an accountable care organization (ACO), I lead monthly patient-centered medical home (PCMH) meetings that involve interprofessional clinical experiences. During these meetings, primary care office staff present patient cases that currently are, or have been, challenging to manage. The registered nurse (RN) case manager will usually start the discussion, but anyone on the team can present a patient case. Round robin type discussions between the physicians, certified registered nurse practitioners (CRNPs), physician Assistants case manager, front office staff, medical assistants and pharmacists, and students of any of these disciplines, are conducted to find solutions or to provide success stories about how patients

Due to these findings patient was directly admitted to the hospital and placed on a heparin drip. On physical exam patient had absent pulses below the right femoral artery. However, there was no discoloration, change of temperature, or sensory as well as motor deficits of the right lower extremity. Patient was taking a low-dose aspirin and red yeast rice for cholesterol management at that time.

Based on the medical report dated 03/30/16, the patient has had pain in the right lower leg, numbness and tingling on the left side as well, rated as 8-9/10.

The patient has some weakness in his left anterior tibialis (4/5) and subtle weakness in his left quadriceps.

Clinician facilitated a family therapeutic session between UC and his Father who is sponsoring UC. Clinician reviewed the Safety Plan and sponsor agreed to utilize the resources provided should the UC need such care. Sponsor indicates he was aware UC would travel to the USA and agreed to provide support and sponsor him. Sponsor indicated he wanted the UC to come live with him so that the UC can have a better education and economic opportunities. Sponsor states he and UC have been separated for many years, however, he has maintained ongoing contact with UC during this years. Sponsor expressed understanding of the responsibility of UC’s overall care and feels he can provide proper care for the UC. Sponsor indicates he will follow conditions

Based on the medical report dated 11/22/16, the patient complains of low back pain, rated as 6-7/10. It is characterized as constant, sharp, aching, and stabbing. He has not found anything that helps relieve the pain. The pain worsens with prolonged walking/sitting, back flexion, job-related repetitive lifting with back strain, twisting movements, and lifting. The pain radiates to the left and right calf. Associated symptoms include

O: Right Lower Leg: Mild edema and erythema present; superficial abrasion (Lateral Shin) 86mm X 52mm without bleeding; tender with palpation; surrounding skin intact; able to bear full body weight; pedal pulse +2;

The patient was subsequently diagnosed with unspecified enthesopathy, lower limb, excluding foot; and other intervertebral disc displacement, lumbar region. As per office note dated 4/14/2016, patient complains of right hip pain radiating to right groin and low back pain. Urine toxicology was performed in the office with pending results. As per appeal letter dated 5/7/2016, the patient experienced heartburn. As per visit note dated 5/12/16, the patient complains of right hip pain radiating to right groin and low back pain. The pain is constant, and moderate in intensity associated with weakness in the right leg. He rates pain as 7-8/10 on visual analog scale and reports medications provides fair relief. In addition, he complains of increased anxiety and multiple nocturnal awakenings secondary to lack of progress. He continues to ambulate with assistive device. The patient ambulates with cane favoring his left lower extremities. Examination of the lumbar spine reveals range of motion to forward flexion of 50 degrees, extension of 15 degrees and side bending of 20 degrees bilaterally. There is tenderness

1.Hormonal imbalances: Heavy bleeding is noted with hormone imbalances usually during early menarche and during perimenopausal period when hormones are changing. Hormone imbalances can also be caused by toxins or unbalanced lifestyles. Symptoms would be weight gain, decreased libido, fatigue, depression, insomnia, hirsutism, thinning hair, and digestion problems. Labs need to be drawn to evaluate LH, prolactin, and TSH level. Her TSH being elevated may very well be the reason for this patient’s abnormal bleeding. Lab work will help diagnose the patient with a hormone issue. This diagnosis cannot be ruled out at this time.

A lot of people around us suffer from different medical conditions each day. It is important for everyone to be able to assess basic medical reports and make a quick diagnosis. In this paper, we will be conducting three different case studies relating to pathophysiological case studies, in order to understand different medical terms related to some very common medical conditions.