CC
Mr. Brann is a 42-year-old male here today for followup from his left cerebellar stroke and left vertebral artery dissection, status post hospitalization in May of 2015
HPI
Since I had seen the patient at his last visit on June 5th, he has gotten married to his fiance Sandra Allen and they are actually planning on moving to Florida. They will be moving on July 31st together to St. Augustine, Florida. He already has an appointment scheduled with a family physician on August 11th and plans on seeing a neurologist as well. He has been to see Karen Lauze, MD in follow up since his stroke. I do not have a note from that visit. She reportedly told Mr. Brann that he could stop his aspirin but to continue with his other current medications.
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He is alert and oriented. Very pleasant.
Neck
Supple. No bruits or JVD. No masses or tenderness.
Heart
Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops.
Lungs
Clear bilaterally with good breath sounds. No wheeze or rhonchi.
Abdomen
Soft and nontender. No masses or discomfort.
Neurologic
His gait is normal. No obvious discrepancies in the eye and mouth movement of his face during our discussions here in the office.
A/P
Whitney Brann is a 42-year-old male here today for
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We talked about the importance of maintaining his medication regimen. I have encouraged him in the future, if he is having any problems with the pharmacy to contact us immediately to assist him and I did write him a refill of his atorvastatin to restart that at 20 mg daily #30 with no refills. At that point, he will be with his new physician and can have his blood work done with them for the lipids and the liver function testing. He does have a lab slip given to me at his last visit for a recheck so that if he does have his visit with her changed in early August, he could do labs for me and I can notify him about any changes that need to be made. He is to continue with his Coumadin. We had a very long discussion about the fact that he has not had his INR drawn as recommended. I reviewed the risks associated with INR value that is too low, as well as an INR value that is too high. He assured me that he would do the INR either today or tomorrow and he knows to contact me within 24 hours of doing the testing if he has not already heard about the result in the meantime. I emphasized the absolute importance of this. He will continue to monitor for any worsening neurologic deficits. Any concerns, he will call 911 and be seen immediately at the
The patient tells me his last visit with Peter Dourdoufis, MD was just last week. I do not yet have a note from that visit. He says that he underwent an EKG and a stress test evaluation. To his knowledge, everything was okay, but he actually has an appointment tomorrow with Dr. Dourdoufis to review everything. No medication changes have been made per his report. He tells me that his blood pressures have been in a good range. Here today, his blood pressure is 126/76. He is not having problems with chest pain, shortness of breath, dyspnea on exertion or lower extremity swelling. He is still working
I was well versed with the patient’s medical history and current treatment, as I was the Long Call IM PGY – II Resident who supervised the medical intern when this patient was being downgraded from the ICU to the medical floor on 5/20/17 (and even suggested to the medical intern to add in her notes that the patient would benefit from statins, ACE inhibition and Spironolactone given CAD, CVA and HFrEF (LVEF < 35%.) The medical team subsequently started the patient on Atorvastatin 40 MG PO QHS, Lisinopril 10 MG PO QD and Spironolactone 12.5 MG PO QD.
BH reports that he takes his medications as prescribed and reports he has tried to adjust his diet in order to decrease his glucose, triglycerides, and cholesterol. He continues to consume
DOI: 8/6/2015. Patient is a 51-year-old female licensed vocational nurse who sustained a work-related injury to her back and hips while moving a client. As per OMNI, she was diagnosed with muscle spasm, pain over the low back and thoracic region. She is status post right carpal tunnel release on 02/26/16.
It is very important to monitor Mr. Cox’s response to therapy. Parameters that should be examined closely are Mr. Cox’s response to his blood transfusion, his lab values, and his response to iron therapy. Mr. Cox should return to the clinic in one month for follow up lab work, medication compliance, and assessment of current and comorbid diseases.
Demographics: Patient is a 32-year-old, moderately built Caucasian female; separated once with 2 children. She lives with her children in her mother’s town house in the North-eastern part of the province. She is currently unemployed and receiving disability from the state from sustained back injury. She has Medicaid insurance; speaks English and practices the Baptist religion.
Nursing care is a dynamic field of practice. The way it looks today is far out greater intense and very structured. It advances itself by the use of nursing theories and evidence based practice. Policies and procedures constantly change with the advancement of technology and science. While caring for the patient in the given case studies, a nurse involved utilizes practical knowledge, a culture care model and transpersonal caring relationship to attain a caring environment (Smith & Parker, 2015).
1. The nurse is asked to implement a new, complex, and invasive procedure and is concerned that this may violate the state’s nurse practice act.
Specialised veterinary nursing is a nurse’s chosen field of practise for example orthopaedic. A specialised nurse may mainly focus on that one selected area when they are in practise. (Hamric, A.B., 2000.) The specialized nursing that is going to be looked at in this essay is in relation to the aftercare of spinal injury patients. Patients that require specialised nursing would be placed in an intensive care unit, where they would be monitored more closely and regularly then that of other in patients.
Registered nurses play a crucial role in encouraging access to healthcare, and participation in health care decisions for both patients and their families. Providing high quality care and treatment helps to support adaptation, recovery, and optimal quality of life for patients facing health alterations, particularly when access to health care is compromised (Brown et al. 2015; Farrell 2017). This case study will explore the palliative care of Kathleen, a 77-year-old Indigenous woman with metastatic breast cancer who lives with her daughter Ann in a remote Indigenous community. Due to her location and diminished access to health care, the patient’s symptom management may be compromised. Registered nurses encourage the patient to access, understand
CHIEF COMPLAINT: This is a post op note from a procedure performed July 21, 2015 by David Lin, MD.
The aim of this study is to provide a detailed account of the nursing care for a patient who is experiencing a breakdown in health. One aspect of their care will be discussed in relation to the nursing process. The model used to provide an individualised programme of care will be discussed and critically analysed.
Mr. B is planning on obtaining an associate degree in nursing. It is possible for him to achieve his ambition. Although schizophrenic, Mr. B has been able to manage his condition relapse-free for the last ten years. For the previous five years, Mr. B has been successfully working as a certified nursing assistant. The above information builds confidence in support of Mr. B because he has been meticulous with his medication regimen and with his psychosocial therapies. Since Mr. B has been able to manage his manifestations successfully, he should consider College for his associate degree. The only pre-condition to Mr. B pursuing his career plans is that he continues with his medication rigorously. Specific issues Mr. B may face while working toward
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,
Congenital Adrenal Hyperplasia (CAH) refers to a complex series of rare but well-studied enzymatic errors of metabolism with deficient levels of different enzymes involved in the synthesis of cortisol (hydrocortisone).