Medical Case Study: Telephone Contact

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.

A 42-year-old female by the name of Mrs. Janice checked into the emergency department (ED) for low back pain. Mrs. Janice has a history of chronic back pain from an

Pt is seen in the ER room and states that he is tired and had tremors so he came to the ER to be on the safe side. Daughter also states that he had tremors in the morning and. Patient's CC is that was tired and had tremors in the morning. States that he stays alone, was worried, and has no past history. Assessment of the head shows no sign of deformities or trauma. Neck shows no sign of deformities or trauma. Chest shows no sign of

Pt's appearance is consistent with that stated by dispatch and pt appears to be in moderate distress due to abdominal pain. With assistance, pt is able to ambulate to gurney from the residence. Pt tracks EMS personnel as they move around him and pt is found to be alert and oriented to person, place, time, and event. Pt's airway is found to be open and pt and he is able to communicate with EMS personnel in full sentences. Pt answers all questions asked by EMS personnel appropriately. Pt's pupils are found to be PERL and no secretions are noted upon inspection of the pt's ears, nose, or mouth. Pt's trachea is found to be midline and no JVD is noted. Equal chest rise and fall are noted upon inspiration and expiration. All four abdominal quadrants are soft and tender upon palpation. A strong radial pulse is able to be palpated by EMS personnel and the pt's skin is found to be warm, pink, and dry. Pt is able to move and has sensations in all four

Pt is a 84 year old Cascasion female living with her husband in their home. Husband reported the Pts Alzhemers has be pergresing for the last 8-9 years. Pt had open heart surgery in 2012, which contributed to the memory loss decline and increasing level of Alzhemer symtoms, husband verbalized. Husband reports they have been married for 19 years. Pt has a sister living Florda, two daughters living in Texas and Wyoming and one son in New York. The children stay in contact with them every other day. Pt reports she worked as a RN at the VA Hospital in New Mexico. Pt is not independent in the home without the husbands assistance. Pt does ambulate well in the home, but does have a walker in needed. Husband assists the Pt all her ADL's in the home and drives her to the store and for MD appointments. Husband currently suffers from Hemochromatosis (too much iron in one's body). Husband reports he manages well with his illness while taking care of Pt at the sametime. Husband reports the Pt's Alzehmers level appears to be stable at this time, but is quite forgetful at times and needs his assistance. Husband said they are managing

A visit note from Dr. Carico, dated 04/25/2017, indicated that the claimant had scalp area pain, upper back pain, and spares the face. Objective findings showed a blood pressure of 136/84 with a BMI of 44.1. She was referred to neurology.

Telehealth is an all inclusive, systematic approach application of care and case management. The program personalizes the delivery of health care services using health informatics, disease management and health technologies. Telehealth facilitates access to care and improves the health of designated individuals and populations.

The pt Poteat, Edward L is supposed to tx today at unit 1087. The unit 1087 is requesting the referral source to send a shortened and missed treatment report in order for the pt to be accepted. This report is not one of the requirements that is needed in order for a pt to transfer to a FKC unit. Also the referral source stated the she sent the report several times and received several conformations and clinic 1087 is stating that they never received it. The referral source and the unit 1087 have been in contact and I am just now finding out about this. Please let me know if the pt is accepted and to see what we can do regarding this patients

0900 Pt in her room lying on her bed with watching TV. Good appetite this morning, Ate 100% of her breakfast. Alert and oriented x 4 and follow commands. Vital sign T96.9, P 72, R 18, BP 113/61, O2 Sat 97 RA. Pt complained pain on her back and rate 6/10 on scale of 0 to 10. skin warm to touch and redness on the area. Lung sound clear and even to auscultated in all lobes. Breath sound regular and even. S1 and S2 auscultated. Abdominal sound presents and actives in all four quadrants. ABD soft, non-tender, no distended to palpate. Pt denied ABD pain. Pt stated last bowel movement yesterday night, medium, soft and formed. Call light within her reach, nonskid socks on, bed in down position. Will continued to monitor……………………….L.Gotora PNS2/WATC

Dr. Navato said on this particular case she was contacted by phone and advised of the serious condition of this patient. Dr. Navato said that she received a phone

On 8/25/2015 S/O EMT Perez was dispatched to PV-509 regarding severe leg pain. S/O EMT Perez knocked and announced his presence at the door and was verbally invited in by the resident a Mrs. Margaret Folkins. Mrs. Folkins stated that she had been in severe leg pain the entire day and she was having difficulty resting. Mrs. Folkins also stated that she was at the hospital for it the day prior because of it but the cause of the pain couldn’t be diagnosed. S/O EMT Perez asked Mrs. Folkins if she had fallen recently and if that was the reason for her visit to the hospital prior. Mrs. Folkins stated that she fall’s all the time but that wasn’t the reason for her visit to the hospital yesterday. The reason for Mrs. Folkins visit to the hospital yesterday

Underserved and Low-income populations face high rates of untreated dental diseases due to low access to dental treatment. One of the main causes of this problem is lack of participating dentists or poor distribution of dentists due to transportation problems. Untreated oral diseases are often seen in low-income communities and underserved populations The most common oral diseases that manifest in underserved populations are periodontal diseases and dental caries

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

During the 1990s, Veterans Health Administration (VHA) has used information and communication technologies to provide first-rate, broad primary and specialty services to its veteran population. The VA, Office of Telehealth Services (OTS) offers a program called Care Coordination/Home Telehealth (CCHT) to make tedious for veterans for the growing health issues occurring across the globe, i.e. diabetes, heart failure, PTSD, and a host of others. I think these have become an epidemic in the veteran community, due to the constant overseas deployment in the recent years of conflicts.

Patient was here with cousins to be seen. This occurred at end of the visit approximately 1:15 pm. I was called by Madelyn Ramirez (PCT) that there was an incident in the exam room. I spoke to the mother, she said he was fine that he did not hit his head. No injuries noted, mother decline being evaluate by provider. But, patient was evaluated by Dr. Ritchin after fall.