Patient Case Study: UAB ED For UTI And Kidney Stone

He admits to a 25 pound weight gain over the last few months. The patient was

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.

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)

This is 38 year old white female. Patient has several issue, chronic back pain, left eye blindness, leg neuraliga and numbness, insomnia, depression Hep B&C positive. Patient reports MVA 18 years ago, lost her mother and father and injured her back and lost her right eye sight. Patient has a history of chronic depression and night terror and she was taking seroquel. Patient has impaired hip joint immobility related injury and chronic pain. Patient reports she is depressed but denies thoughts of suicide or homicide. Patient states she has a history of iv drug use, and her sexual encounter are only with other females. Patient was diagnosed with Hep B &C and doesn't know what to do. Also it has been a long time since she had her eyes checked.

This is 39 year old AAM. Patient is here with several complaints. Patient has no medical condition, or long term medications. Patient denies any other issues except as listed.

This 54 year ld AAM. Patient has a history o fDM, HTN, and hyperlipidemia. Patient's current medications are Glipizide 10 mg BID, ASA 81 mg QD, Triamtereine /HCTZ 75/50 mg, Pravastatin 40 mg QHS, and lorsatan 300 mg QD. Patient states he is taking all mthe medications as prescribed, and he thought he was doing fine. Patient states no one in the Federal Prison System had checked his A1C in several years. The patient's A1C today is greather than 14 %. Patient denies buller vision, headache, chest pain, SOB, N/V/D, or fever. The patient denies decreased sensation of his feet, increased thirst or urination. Patient denies any depressive moods. The patient is here with his wife and had a long disussion with the plan of care for his DM, HTN, and

Past Medical History: The patient has a history of end-stage renal disease secondary to IgA nephropathy, hypertension, alcohol abuse, biopsy proven liver cirrhosis, history of right leg cellulitis,

The offender returns to clinic today for a number of issues. 1. Diabetes mellitus type 2: This has been well controlled on oral metformin and the patient reports that she has no concerns in this regard. Last hemoglobin A1c was 5.9 about a month ago and all other labs within normal limits except for a quite high LDL at 171. She has not been on cholesterol-lowering therapy in the past. In addition, her TSH was very slightly elevated at 4.740 which can be considered the upper limit of normal. She has not noticed any significant constipation, excessive fatigue, or cold intolerance but she has had continued trouble with weight gain and thinks she may benefit from some low-dose thyroid replacement. 2. Chronic low back pain: At

AA explained the case and its etiology Gc is 75 and had been in and out of the center many times never completed treatment at detox, AA as well highlighted that Gc will not be admitted again to the center

The patient is a 44 year old male who presented to the ED via LEO under a IVC through DayMark. The patient reports recent medication changes from his usual medication h had been taking for 9-10 years. The patient was discharged from HPR yesterday for safety and stabilization. The patient denies suicidal ideations, homicidal ideations, and symptoms of psychosis. The patient dos not appear to be responding to any internal stimuli. The patient is calm and cooperative.

A review of her medical record indicates she was admitted to MHS on 5/7/2017 with Weakness, fever and chills for 2 days and diagnosed with lower respiratory tract infection and possible UTI. She was started on antibiotics and IV fluids with adequate response. She was also noted to have mild fluid overload and pulmonary congestion on chest x-ray which were treated with. Patient had a 2-D echo on April which shows a preserved systolic function of left ventricle with only mild diastolic dysfunction. She is on marijuana adjunct therapy for her pain. She suffers from chronic HTN, chronic depression, which remained unchanged and chronic anemia. She is current follow by Dr. Iannotti for oncology and is currently on chemotherapy.

A review of his medical record indicates that he suffers chronic urinary tract infection with retention. He has a suprapubic catheter in place. On 1/8/17 he was ordered UA, C&S due to hematuria. He has new onset depression and was started on Cymbalta by his PCP in December. He suffers from chronic pain due to his arthritis and osteoporosis. He also suffers from co-morbidities of HTN-chronic and stable, anemia-chronic, Rheumatoid arthritis which is chronic and CHF-chronic.

This is 41 year old white male. Patient is here complaining of back pain that is radiating down to his legs, sharp pain. Patient reported that he was attacted and was severely bitten and also was stumped on his lower back was hospitalized for several weeks , about one month ago from that he is also experiencing post dramatic distress syndrome. anxiety and panic attach and nightmares. Patien denies chest pain, SOB, N/V/ D,or fever. Current pain 6/10. Patien is a current tobacco user with a 30 pack year history, histroy of alcohol abuse, and substance abuse, currently in a group home.

This is 53 year old WF. Patient reports chest congestion, thick green sputum production, chills, fever, and generalized body aches for the past 3 days. Patient states, everyone at the Love lady Center are sick and it's just going back and forth between eachother. Patient denies chest pain, SOB, N/V/D. Patient staes she hsa cut down on her cigatettes to 6 cigattes per day from one pack per day. Patient is currently atking prozac 40 mg QD and currently denies depressive moods. Working on getting Blue Card from Cooper Green for her GI issues as previously discussed.

My interviewee was a 70-year-old female who was re-admitted to CCC in March 7th, this year. Her primary diagnosis was status post CVA with left hemiplegia. Other past medical history includes major depressive disorder, hypertension, hypothyroidism, COPD, anxiety, GERD,