No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,
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.
Patient “DD” is a 56-year-old woman who was admitted to a nearby hospital for respiratory failure. With the only previous medical history being chronic bronchitis, she was diagnosed upon admission with COPD, anemia, hypoxia, moderate anxiety, and dyspnea.
Client indicated that she suffers from asthma NOS with Acute Exacerbation, allergies rhinitis, insomnia, unspecified. Client reported no changes in her medications and she is seen by Dr. Muhammad M. Haque/PCP.
You had a recent episode of lower leg edema (swelling) which your primary care physician prescribed Lasix (medicine to get rid of fluid). You vital signs were within normal limits and there was no oxygen saturation (rest) provided. Your electrocardiogram (recording of your heart activity) was Sinus (normal). In emergency room you received 30 milligram of Lovenox (blood thinner) and Methylprednisolone (medicine to help with breathing). You were admitted, started on aspirin, Cardiac enzymes (test) were done and your first troponin (test) was negative (no other results provided). You were continued on Prednisone (medicine) 10 milligram daily; restarted on Coumadin (blood thinner), Diltiazem (medicine), and a low salt diet was recommended as well as you received Albuterol via a nebulizer (breathing treatment) every 4 hours. Your pulmonary (breathing specialist) consult states that the shortness of breath was most likely due to deconditioning (changes in body with inactivity), obesity (over weight), and less likely due to Sarcoidosis (inflammatory disease). Chest pain syndrome was musculoskeletal (muscle-bone) in origin as it was reproducible (pain present when area is pushed
This is 51 year old AAF. Patient is here complaining of several issues as listed. Patietn reports for the past several days she had increased SOB at rest, non-productive cough, adiouble wheezes. Patient denies chest pain, N/V/ D. Patient is a current tobacco user wit 20 pack year hisotyr. Denies use of alcohol or illicit drug use. Denies depressive moods, current pain 3/10.
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
Janice’s recent symptoms are most in keeping with an infective exacerbation of her asthma and it may be that the previous infection has only been partially treated. I have given her a repeat script for Augmentin and advised her to continue with the higher dose Symbicort for now.
History of Present Illness: I last evaluated Ms. Dall at the end of June for a chronic cough. She had previously been given the diagnosis of COPD, as she is a 240 pack-year smoker who continues to smoke. She states that her cough is similar to when she has last seen me as previously believed she had an acute viral illness that led to her persistent cough She does have some shortness of breath which is stable, but worse on hot, humid days like today. Once again, she is smoking up to a pack to two packs a day and she does not have any interest, at this point, in quitting.
A 45-year-old male comes into the emergency department with symptoms of acute dizziness, dyspnea, chest pressure, and palpitations. He states that he feels that his heart is “racing.”. He has a history of hypertension (HTN) and coronary heart disease (CAD) status post one bare metal stent. He is currently on clopidogrel, aspirin, metoprolol, and Llisinopril. His BP blood pressure is 87/60 mmHg, pulse heart rate 160–-170 beats/min, respirations rate 26 breaths/min, oxygen saturation 90% on room air, and afebrile. His physical exam has pertinent positive findings of diminished global breath sounds and rapid sinus heart sounds. He has no jugular venous distention (JVD), abdominal tenderness, nuchal rigidity, lower extremity swelling, or focal
Heart & Peripheral Vascular (2 points): Carotid arteries 2+ bilat, external jugular visible in supine position, not visible when elevated. No visible chest wall pulsations, no heave, lift, apical pulse in 5th intercostals space at midclavicular line, pulse 61, regular rate, rhythm. Aortic, pulmonic valves, S2>S1. Erb’s point, S2=S1. Tricuspid, mitral valves, S1>S2. No gallops, murmurs, extra heart sounds. All pulses present 2+ bilat, no lymphadenopathy. Legs absent of varicosities, tenderness, edema, atrophy, warm bil. Epitrochlear lymph nodes not palpable, no Homan’s signs.
History of Present Illness: Ms. Barrett was seen by me on July 30th for a cough and possible infiltrate on her chest x-ray at which time I prescribed her a seven day course of Avelox. Earlier in the week, she had complained of a persistent cough and I ordered a subsequent CT scan of the chest to evaluate the potential abnormalities. She states that today that since then, her cough is slowly resolving. It mostly occurs at night when lying flat. She does have a history of allergic rhinitis and postnasal drip, which may also be a contributor. She denies any fevers or chills. She is chronically using her inhalers as previously prescribed. She is also on supplemental oxygen for her chronic hypoxemic
I am also suspicious that she is struggling with eustachian tube dysfunction. We talked about treatments. We briefly discussed the idea of antibiotics, but at this point, my suspicion is this is still more viral. She is aware of what to be watching for and knows to call me if there is not improvement here through the course of the rest of the week or into early next week. We talked about good hand hygiene to avoid new illness or spread to others. One of her biggest complaints is just coughing at night and keeping her awake. I did write her for Tussionex cough syrup 5 mL twice daily p.r.n. four ounces with no refills. She is aware of side effects and is aware of sedation, in particular. She will not take it if she is driving or with any other sedating medication. She will monitor her symptoms, in the interim. She will continue with her Flonase and if there is no improvement here into next week or so, consideration for antibiotics can be done. If there is acute worsening in her respiratory status or other concerns, she will seek care if necessary and will otherwise follow up as needed with Dr. Lilly. All questions answered in the office