Present Illness History

Mr. John Doe is a 65 year old male admitted with complaints of dyspnea for the past week which has gotten worse when lying down and with exertion. He complains of a cough, especially at night and has also noticed swelling in his legs bilaterally. The patient has a history of hypertension. On examination, wheezes are noted in the lungs bilaterally as well as 2+ pitting edema in the lower extremities bilaterally. The patient is sitting up and in no acute respiratory distress.

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

Patient was in the ER room when first seen. PT was with her family members and family states that she speaks little English and that she has had abdominal pain for the past day along with bloody stools. Family states that she is on calcium supplements and no other medications. Last oral intake is 24 hours ago. Family states no known past medical history. Pt is in the hospital bed in the fetal position and towards the right side. Patient's airway is clear and breathing is normal. Skin is warm and dry. Patent is AAOx4. Assessment of head, neck, and chest show no signs of deformities. Abdominal area not assessed due to severe pain. Back is without deformity. The upper extremity shows no sign of deformities or trauma. The lower extremity shows

The general health of the patient is currently being compromised due to present illness mentioned above, but is stable. L.H. reports his usual health to be, “normal and not too crazy like this”. Patient has some fatigue noted while conducting daily activities; No recent weight change, fever or sweat. The skin noted to some discoloration on upper right side of back. There is no pruritus, rash or lesions present. Bruises noted bilateral on arms. Patient reported taking baby aspirin as daily medication. His hair is greying and thinning with no hair loss.

A chest X-ray and CT scan result demonstrated a cavitation of the right lower pulmonary lobe. This result alone along with Bob’s history of smoking is a big red flag related to lung cancer. Bob’s history reveals that he has been smoking a ½ pack or more per day for 37 years. According to a study done on the diagnosis, staging, and treatment of lung cancer, habitual smokers have the highest risk of developing cancer of the lung than any other cancer (Herth, Eberhardt, Ernst, 2006). The study also concludes that a related association with lung cancer is swelling of the tissue, lung tumors and/cavitation, lymph in the bronchioles, and paratracheal areas. The swelling can lead to an obstructed airway, which matches Bob’s symptoms as well. Chest pain, stridor, and chest pain are all indications of complications in the respiratory system.

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.

HPI: Margaret Elliot is a 52-year-old Caucasian female that is presenting with shortness of breath that has recently worsen. Mrs. Elliot states that her problems began 20 years ago when she had bronchitis, which she consistently has 2-3 times a year. She said that her symptoms have been getting worse the last 2.5 month, but have severely worsen over the past three days. She states that it has been restricting her daily activities and has been troubling her while sleeping lying down. She states that her symptoms improve alittle when she takes her medications. She also states that her symptoms worsen when she tries to walk across the room

1. Describe why past medical history information in a health history can be important when considering the patient’s current chief complaint. (5 points)

SW is a 65 year old white female who is 5’8” tall and who weighs 155 lbs. Her IBW is 140 lbs. and she has an IBW % of 110.71. She went to emergency department on February 1, 2015 complaining of shortness of breath and coughing since November, 2014. Her medical diagnosis includes multi-drug resistant organism, diabetes, COPD, and lung cancer. Her laboratory result shows that she has an elevated WBC of 17.4 on February 2nd and it increased to a critical level of 32.2 the next day. An elevated WBC usually means an infection is happening in the body. Her RBC is elevated at 6.19 which could mean hemoconcentration or it could be due to her COPD. Her decreased MCH of 25.0 & 24.8, her Neutrophils of 13.8 and her elevated RDW of 18.2 & 18.4 could mean that she’s having some iron deficiency anemia. Her laboratory also shows that her albumin is low which can be from prolonged immobilization, decreased nutritional status or worse it could be due to her lung cancer. Her low Sodium of 132 and Chloride at 93 may be due to her diet or medication side effects. Her serum glucose at 118 is elevated which can be from her diabetes or from stress of being in the hospital. Her Platelet count of 405 is normal and her BUN of 5 is also within range. Her arterial blood gas is showing compensated imbalances. Her pH is 7.35 which is normal on the low side. Her PaCo2 is 65.2 which is very elevated, her PaO2 is 66.4 which is very low, her HCO3 is also very elevated at 35.3.

The following case scenario is based on a fictitious patient, and it would be use on this paper as a guidance to develop a patient and family teaching plan. The situation: Mrs. Marquez, a 39-year-old Caucasian female was admitted into the Emergency Department due to complains of shortness of breath and anxiety. Patient cannot take deep breaths, appears overweight and denies Allergies to medication. The background: Patient has medical history for panic attacks, atrial fibrillation, and Grand Mal seizures; however, patient is not constantly taking her seizure medication. Patient previously had a cholecystectomy, and smokes 1 pack of cigarettes per day for 12 years. The Assessment: Patient vital signs 98.8° F oral, 109 heart rate, 26 respiratory rate, 150/86 blood pressure, SaO2 97% on room air. Denies pain. Neurological; Patient is 65 inches tall, weighing 246 lbs. She is able to move all extremities with strong pushes and pulls. States her “last seizure was two months ago.” Respiratory; Respirations are even, deep, and rapid. Lungs are clear on auscultation. Cardiac; EKG reveals atrial fibrillation; patient states, “It feels like my heart is racing at times.” Pulses are palpable +3 all extremities; capillary refill is instant. GI; Abdomen soft, no distended, and no tender with bowel sounds present in all four quadrants; skin is intact and warm. Current medications: Dilantin 400mg PO BID, Lexapro 20mg PO daily, Metoprolol 25

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.

Respiratory: Patient denies having history of lung diseases such as asthma, emphysema, bronchitis, pneumonia, or tuberculosis. She also denies having chest pain with breathing, wheezing or noise breathing, shortness of breath, hemoptysis, sputum, toxin or pollution exposure. Patient states that she had common cold with some productive cough for about a week last month. Also, patient states that occasionally she experiences shortness of breath when she runs for more than 40 minutes. Patient states that her last chest x-ray was 1 years ago, and the results were negative.

Mary Smith, Female, 56 years old, presented to Emergency Department with abnormal Chest Xray, fever, chills and generalized weakness on Friday, 10/31/2014. Per patient, she came to visit her physician after she started feeling abnormally tired at work. After consult, physician ordered Chest Xray that showed bilateral infiltrates in lungs. Given previous lung disease history, and history of COPD, physician suggested a visit to a local Emergency Room, after which Mary Smith was admitted to an outpatient unit for observation. Additional investigation of past medical history revealed that patient has Chronic Pneumonia due to Mycobacterium Avium Complex and Gastroesophageal reflux disease. Admission history revealed that Mary Smith lives with her spouse and work in a local retail store. Patient denied smoking history, alcohol consumption history, drug use history. Psychosocial assessment revealed that patient’s house was burglarized few months ago, otherwise no other stressful factors added. Patient presented with no known allergy history. Current medication assessment showed that patient takes probiotics,

Forms of violence and trauma resulting from the Indian Act during colonization are embedded in social determinants of health and are directly linked to a disproportionate burden of illness. Before colonization, Indigenous communities had ‘subsistence cultures’, which means that nutrition, diet, and medication were provided through their local ecosystem (Richmond & Cook, 2016, p. 3). During colonization by European settlers in Canada, conflicting ideologies about ways of living caused challenges between the Indigenous and Europeans (Richmond & Cook, 2016, p. 3). The need to manage Indigenous populations took the form of the Indian Act of 1867, which gave the federal

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.