Pt Assessment Paper

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.

What I learnt from the third video and the transcript from Amy Barkley a PTA from Michigan, which I didn’t know before is that, in some state like Michigan, You could worked as PTA without being licensed. But things have changed. Now, you have to be a graduate from an accredited Physical Therapist Assistant program and also pass a state exam to earn a license.

Two right chest tubes at the right lung base were inserted and secured with surgical sutures. He was transferred to ICU after he was discharge from anesthesia care. Post-operatively despite chest tubes, he continued to have a worsening crepitus. Chest x-ray was done revealing right pneumothorax with subcutaneous emphysema, right middle lobe spiculated lesion and positive lesion in stomach. He was transferred to the floor for some time, but was returned back to ICU after he developed an increased in subcutaneous air in face and neck for which a 3rd chest tube was placed through a prior surgical incision. During his hospitalization, his vital signs worsened with blood pressure of 104/56 mmHg, oxygen saturation of 80% on room air, respiratory rate of 38 breaths per minutes and a temperature of 35.6 °Celsius. After two of the three right chest tubes have been removed, he was advised of needing to go home with chest tube or heimlich valve. Then, he was given specific discharge instructions including chest tube and pleurevac care, wound care, activity, diet, and meds. He verbalized understanding and agrees with plan after he was advised to follow up in the office this week with the probability of removing the chest and to return to Emergency Department if his symptoms

The patient is a 75-year-old gentleman who presents to the ED brought in by wheelchair with complaints of falls and injuries. H he presents also with pain it's chronic it radiates down his left leg symptoms became worse over the past 5 days is also consult related having weakness neck pain in his medical history is significant for enlarged prostate hypertension good cancer carcinoma of the neck and liver carcinoma patient also does some indication that he had a liver transplant 14 years ago on a CT brain done in the ED revealed him to be highly suspicious for normal pressure hydrocephalus number of the lumbosacral was noted to have mass in the sacral area highly suspicious for metastatic cancer is also known to have cervical myelopathy in

This is a 92-year-old patient who fell apparently at home and was found lying on the floor at home. She reports decreased po intake, constipation and some episodes of bright red blood per rectum during bowel of movements. She was seen and evaluated in the emergency room. She has a past medical history of arthritis, osteoporosis, thyroid disease and frequent falls. On exam she had diffuse dry skin, she has multiple bruises on the left upper extremities and hips. She had a press pressure ulcer stage II on the right buttock area. Her laboratory work her calcium was 12.0. Her potassium was 4.3. Her BUN was 46. Her creatinine was 1.2. Her blood cell count was 14.50. The admitting diagnosis was hypovolemia, hypocalcemia, severe malnutrition

The patient is 69-year-old gentleman who presented to the ED complaining of dizziness and nausea. The episode lasted about an hour. It occurred when the patient was sitting in the courthouse. He also reports some abdominal pain, dizziness, headache and nausea. He denies any chest pain or shortness of breath. He has experienced similar episodes in the past. The patient was last seen by his primary doctor on July of 2014. He has a past history of non-insulin-dependent diabetes mellitus, anemia, hypertension, prostate CA, skin cancer, syncope, GERD, coronary bypass grafting with stenting, unstable angina, right carotid stenosis, some autonomic dysfunction, pacemaker in place and history of TIAs and CVAs. The patient was placed in observation

A nineteen year old, white female is admitted to the emergency room with sharp pain in the abdomen and no previous medical history. The symptoms the patient reports include slight abdomen pain accompanied by vomiting and a low fever beginning a few days before seeking medical help. A few days later, the abdomen pain worsens and moves above the appendix. The patient reports that the pain continued to worsen and then began to feel much better. The night the patient was admitted to the hospital, she says that the pain had come back and was now worse than it had ever been (1). Upon arrival at the hospital a nurse will examine the patient and various exams will be performed; these will include an exam to see if the abdomen is inflamed, a urine test,

The patient is home bound related to her inability to leave home without the assitance of one or more person and the usage of a modality such as a Walker , the patient respirations are even and unlabored, the patient has tub grips in place to bbel, the patient also has legs elevated is recliner chair, the patient stated that she has occassional pounding of her chest and elevated blood pressure, the pateint caregiver stated that the patient. Blood pressure systolic was over 210 on last night, the patient blood pressure elevated at this time , the skilled nurse. Called Dr. Druhva and spoke with Levon ad informed her of the Patient elevated blood pressure for several days and the patient elevated

The patient is 65-year-old gentleman who has recurrent presentations to the ER first 1/22/2017 for a fall. Discharged 1/26/2017, another fall, admitted to having some alcohol to drink, discharged, a repeat visit on 1/27 again because of falls, discharged with instructions to see Dr. Silva the following Monday only for the patient to return to the ER about 5 or 6 hours later. He evidently has no place to live since the death of his wife a year ago. He states he lives in the laundry room of the the building and he was kicked out and again has fallen. His laboratory work shows he has a CO2 of 15, which is unexplained. He does have a left below the knee amputation with pain, swelling and some cellulitis of the lateral aspect. Evidently

The patient is an 87-year-old female who is brought in by her daughter because of ongoing dizziness over the past several days which is worsening. The patient keeps getting out of bed and moving around. She is also complaining of retrosternal chest pain which is worse with walking and exertion. She is unable to ambulate at home. It is to be noted she had a recent cardiac workup as an outpatient which was negative. She also had recent EGD that demonstrated a small hiatal hernia, as well as a large to what duodenal diverticulum. Her medical history is significant for diabetes mellitus with the known neuropathic arthropathy, hyperlipidemia, hypertension, chronic kidney disease stage III, as well as systemic lupus erythematosus. The patient

Mrs. B.N., a Caucasian 60 years old female admitted on March 15th morning through Cox South emergency department after transport by the Emergency Medical Service Team. Her sister called 911 when she passed out while she was on her bedside commode at home. She presented to the emergency room with short of breath, sharp chest pain, and left leg pain. She was also nausea and vomiting that has been present for several days. The patient basically indicated she has pain all over. Her left leg pain was worse than usual. She vomited multiple times per day with occasional small amount of blood. She has been dizzy, disoriented, and passed out several times at home in the past few days. She reported a subjective fever, headache, and has been unable to

0900 Pt back to his room after breakfast lying down on his bed watching TV, call light within his reach. Ate 85% of his breakfast. Focus assessment completed. Alert and oriented x 4 and follow command. VS T 97.2, P 89, BP 120/60, O2 Sat 92 on 3-liter nasal cannula Pt denied pain at this time and rated 0/10 on a scale of 0 to 10 Heart sounds regular and even, S1 and S2 auscultated. Lungs sounds wheezing in all lobes during expiratory. Bowel sounds present and active in all four quadrants. ABD soft and non-tender to palpate. Pt denied ABD pain. Pt reported bowel movement this morning, (2/18/16)

The patient is an 86-year-old female who presents complaining of severe back pain. She states that she is in the ED on Monday and Tuesday. They gave her pills for the back pain but they were not helping her. She states the pain is acute. She does not know what the mechanism of the injury would be. The pain is located in the lower back. They do not radiate. The episodes began about a week ago. If she sits absolutely still the symptoms are relieve but are aggravated by any movement. Her medical history is significant in that she is has end-stage renal disease on hemodialysis, had a DVT in her right upper arm, chronic obstructive pulmonary disease, congestive heart failure, she had a recent bowel perforation and she now lives with a colostomy.

Vital signs were as follows: blood pressure 118/80 mm Hg; pulse 84 beats/minute; respirations 16/minute; oxygen saturation 99% on room air, temperature 97.1 F, body mass index 27.45 kg/m2; pain 3/10. The patient was in no acute distress. Lungs were clear to auscultation bilaterally with no use of accessory muscles. Cardiac exam revealed normal rate and rhythm, no murmur, gallops, rub or jugular venous distention. His abdomen was non-distended, non-tender, without masses,

Does not have a pulmonary embolism. Severe dyspnoea, RR 28 breaths per minute, SaO2 of 91% and diagnosed with COPD. Is constantly tired.