Medical Case Summary Reflective Disorient

A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he

Susan is a 78 year old widowed lady who was admitted to a medical ward following an episode of coffee brown vomiting and breathlessness. Susan has a past medical history of chronic

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.

Her drug screen showed positive benzodiazepines and blood alcohol was negative. Troponins were negative. Also, her initial work up showed acute kidney injury with a creatinine of 1.84, and potassium of 5.8. Her chest x-ray showed small amount of infiltrate in the right lower lobe. The CT scan of the head did not show any acute changes. The abdominal CT scan showed constipation and 6 mm opacity in her bladder. She had an electroencephalogram (EEG) which revealed diffuse generalized nonspecific encephalopathy. In addition, there was slowing of the left hemisphere consistent with left intracerebral lesion. The assessment diagnoses were acute respiratory failure (ABG of 87.287, pCO2 of 45.2, pO2 of 380 and biacarbonate of 20 on vent settings), altered mental status, attempted suicide, infectious process, medication use, hyperglycemic nonketotic, and less likely cerebrovascular accident given that her CT scan of the head was normal. She was admitted to the Intensive Care Unit under the care of Dr. Modupe Kehinde. She was intubated for airway protection and remained intubated until 5/23/2016 (7 days). She was on ventilator and was given nutritional support

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

This 49-year-old African-American female was presented to Truman Medical Center - Emergency Department, on November 24, 2014 due to nausea, vomiting, and headaches for two days. She stated that she has no appetite and left lower quadrant pain. She was previously treated at Saint Luke Hospital - Emergency Department for her diarrhea, nausea and vomiting before transferred to TMC Hospital. At SLH - ED, she was given some Benadryl, Tylenol and IVF which showed no improvement and continue to have three to four times watery diarrhea with no blood or mucus associated with nausea and vomiting. Her medical history is significant of diabetes mellitus type 2, hypertension, intracardiac loop recorder and cerebro-vascular disease. Vital signs included a high oral temperature

“The patient is Adam Rudd, a 78 y/o white male with a history of hypertension. He has been diagnosed with hypertension past 15 years and is on anti-hypertensive medications and aspirin. He is very weak and short of breath. He is accompanied with his longtime friend Jennifer, who reports that Rudd was looking very weak and was complaining of severe headache and blurred vision before coming to the hospital. He is 5’9” and weighs 270 lb. Vital signs recorded were: oral temperature 98.20 F, BP 224/120 mm Hg with a heart rate of 102 beats/minute and respiration of 24 breaths per minute. The pulse oximetry reading was 94% on room air. He is complaining of severe headache and blurred vision. Rudd said that he did not take his antihypertensive medication or aspirin since he ran out of pills. He has not been taking his medication for past 15 days. He reports no known allergies to any medications or other substances.”

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

Patient is presented to the ER with her mother after having been referred by her pediatrician. Mother complains nine month old patient is exhibiting symptoms she herself had been experiencing over the last year and a half or so. Mother and daughter share symptoms of intermittent fevers, swollen lymph nodes, weight loss/inability to gain weight, extreme fatigue with nocturnal wakefulness. The mother said she also experienced some muscle pain, confusion at times and possible personality changes. The mother told the ER doctor she attributed her symptoms to pregnancy but they continued after giving birth. They started off very mild but have been becoming more severe over the last year. During physical examination patient states having

The patient is 66 year-old male who is brought to St. Joe's ER by BLS after being found with altered mental status at home. The patient reports he used heroin 2 days prior to admission. The patient was found by his brother hallucinatin with bladder or bowel incontinence the morning of presentation. The patient has not eating in approximately 4 days. The patient himself denies having any complaints, but he is a very poor historian. His medical history is significant for prior heroin and cocaine abuse, alcohol abuse of unknown duration, hypertension, cirrhotic liver, he has had an anterior cervical discectomy of C5-C7 with anterior compression in May of 2012 and a closed reduction of C6-C7 billateral dislocation , cholecystectomy in the

Your mother was brought in by the ambulance on January 19. She was having difficulty speaking, swallowing and was showing signs of paralysis on her right side. Your mother has a history of high blood pressure and high cholesterol. Your father said that she is taking medication daily. Your father said that your mother has been fine until her face started drooping and she complained of having a headache. Your father stated that she was unable to drink her coffee without it spilling down her face and she was reaching in the cupboard when her arm started to fall. She was getting up from the kitchen table when she collapsed and was not able to get up without help. Your mother then was not able to move and could not swallow or talk.

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

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.

Case Description: A 25 year old healthy male who is a very active running back in the sport of football came to the emergency room. The patient has a history of previous

History of Present Illness: Mr. A. O. a 66 year-old-African American male came in the clinic for a monthly routine follow up visit complaining of severe cluster frontal headaches that radiates to his left eye, pain level eight out of ten, on and off for three days lasting for 30 to 45 minutes. He stated that he takes Tylenol 1000mg orally every eight hours with mild relieve, and will like his blood pressure medications increased. Also, he complained of edema to the upper and lower extremities, and right hand pain when he tries to make a fist. However, he denied shortness of breath,