PAST MEDICAL/SURGICAL HISTORY: As above. SOCIAL HISTORY: Status post heavy smoking, 50+-pack-year history. He quit 10 years ago. Status post alcohol abuse, quit 3 or 4 years ago. He lives by himself and no longer drives but has 2 daughters here in Miami who take him where he needs to go. FAMILY HISTORY: Patient’s wife died 14 years ago of COPD due to lifelong smoking. Brother has diabetes mellitus. Unremarkable family history otherwise. REVIEW OF SYSTEMS: No fever, no nausea, no vomiting. Patient has incontinence of bowel. No shortness of breath, no chest pain, no palpitations. PHYSICAL EXAMINATION: Well-developed, well-nourished white male who is alert and oriented x3. Wears bilateral hearing aids. Afebrile with blood pressure 130/70. NECK: No carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: S1, S2 normal. No murmur. No S3 or S4. ABDOMEN: Soft, nontender. No arterial bruits. No masses, no organomegaly. EXTREMITIES: No edema. No pulses present in the lower extremities. The right great toe is absent. The left great toe shows a 2 x 1 cm deep ulcer with redness around the toe with pus extruding. PLAN 1. Get consult with Dr. Beth Brian, Infectious Disease. 2. Follow up with Dr. Hirsch, Orthopedics. (Continued)
X is a 55 year old male h/o MRDD who presents with sepsis 2/2 intraabdominal free air. Pt had recent peg tube placement at another hospital 5 days ago. Per family patient has had increased work of breathing over last 24 hours, was intubated by EMS on route. CT was obtained upon arrival to ED which showed intraabdominal free air, bowel dilation, and large stool burden. Patient was admitted to ICU with sepsis pathway orders started.Patient underwent emergent exploratory laparotomy with repair of perforated viscous.
HISTORY OF PRESENT ILLNESS: This 46-year old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis presents to the emergency room after having had 3 days of abdominal pain. It initially started 3 days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o earlier around 6am, but he now
On examination, the patient was hot to the touch, and right upper quadrant was tender on palpation and abdomen was soft. The patient had dressings on her abdomen from the site of the surgery, but the appeared to be clean and did not have puss coming from
The patient complained of right lower quadrant pain and of feeling faint. Dr. O'Donnel documented a chief complaint, a brief history of present illness, and a systemic review of the gastrointestinal system and respiratory system. Dr. O'Donnel also documented a complete examination of all body systems, which included all required elements. Medical decision making was of moderate complexity.
The patient is a 45 year old man who had GI surgery 4 days ago. He is NPO, has a nasogastric tube, and IV fluids of D51/2saline at 100 mL/hr. The nursing physical assessment includes the following: alert and oriented; fine crackles; capillary refill within normal limits; moving all extremities, complaining of abdominal pain, muscle aches, and "cottony" mouth; dry mucous membranes, bowel sounds hypoactive, last BM four days ago; skin turgor is poor; 200 mL of dark green substance has drained from NG tube in last 3 hours. Voiding dark amber urine without difficulty. Intake for last 24 hours is 2500mL. Output is 2000mL including urine and NG drainage. Febrile and diaphoretic; BP 130/80; pulse 88; urine specific gravity 1.035; serum
Your white blood count (lab test) was 16.6, computed axial tomography (test) of the neck showed mild edematous (swelling) and enlargement of the right tonsil without abscess (pocket of infection). You received intravenous treatment (through the vein) fluid bolus (fast) in the amount of 2 liters, Morphine (pain medicine) for pain, Decadron (medicine that decreases swelling), Clindamycin (antibiotic) and Unasyn (antibiotic) all intravenous (through the vein) stat (immediately). Your blood cultures showed no growth. You were admitted with intravenous (through the vein) fluid at 60 an hour (rate), Zosyn (antibiotic) intravenous (through the vein) every 6 hours, Heparin (medicine to thin blood) and Tylenol. You were seen by an Infectious disease (specialist) for a consultation and continued on intravenous (through the vein) antibiotics. Based on the Interqual guideline criteria (a decision based program to determine medical need) for infection, the clinical guidelines were not met because there was no documented failed outpatient anti-infective treatment; you were not Immunocompromised (body not able to fight infection or gets infection easily) and your temperature was not greater than 99.4
Ms. C. is a 53 y/o female with admitted to 2A with complaints of severe right abdominal pain. She is a pleasant lady with a friendly demeanor and asks for very little assistance. Mrs. C is morbidly obese which makes it difficult to get out of bed without assistance but for the most part, she can ambulate and walk around on her own once she is out of the bed with the assistance of a walker. Because of her obesity, Ms. C has several skin folds throughout her body, which make a great medium for fungal infections. The area underneath her skin folds is red and irritated. Ms. C has had oliguria for the past several days and is outputting very little to no urine. A foley catheter has been placed in order to remove any
This patient presented to the emergency department (ED) with pain in his upper right quadrant and flank. He reported experiencing abdominal distention
patient tested positive for H. pylori and wakes up at night due to cramping pain with bloating, so it is assumed to be peptic ulcer and the status of his condition is uncontrolled. Her symptoms were not improved with over the counter medication, Tums. Therefore, it is not GRED. However, Patient does not need a referral for endoscopy this time around because she does not hat the symptoms vomiting, nausea or dizziness.
A week after initial admission, the patient is on the medical surgical floor recovering from his transverse colostomy five days ago. At 1200 vital signs are as follows, temperature 99.1; pulse 96; respirations 18; blood pressure 141/69; pulse ox is 94% on 1L NC in AM. The patient appears acutely ill and lays in bed with his eyes closed even when family comes into the room to check on him. He is alert and oriented to person, but not place or situation. He appears lethargic and is slow to respond to questioning, this appears to be due to recent administration of pain medication. Pupils are equal round and reactive to light and grips are week bilaterally in hands. Abdomen is firm, distended, and non-tender. Colostomy site appears to be
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