Sample Medical Case Report

DIAGNOSTIC DATA: White count was 13.4, hemoglobin and hematocrit 15.4 and 45.8, platelets 206, with an 89% shift. Sodium 133, potassium 3.7, chloride 99, bicarb 24, BUN and creatinine are 18 and 1.1, respectively. Glucose 146, albumin 4.3, total bilirubin 1.7. The remainder of the LFTs is within normal limits. Urinalysis reveals trace ketones with 100mg per decilitre protein and a small amount of blood. CT scan was performed revealing evidence of acute appendicitis with pericecal inflammation, as well as, dilatation of the appendix and

Day 2 (OB) – Vaginal Birth and preparation for birth. Hanging Pitocin, and Lactated Ringers, and being able to watch an epidural insertion.

Last week Thursday on the orthopedic clinic was a slow but eye opening experience. When I got to the clinic at 8AM, after I was introduced to some of the nurses there, I was immediately assigned to a Medical Assistant (MA) that I had shadow for half of the day. The MA shows me around the clinical and explained her role and responsibility in the clinic setting. During the first several hours, and MA and I were quite busy rooming the patient. Because the MA want me to see how to do thoroughly assessment on a new patient, the MA did a thoroughly assessment and examinations on the first patient we saw. During the assessment, the MA also explained some of the medical procedures to the patient. She did a set of vitals on the patient, particular on new patient, such as blood pressure, height, and weight. We had a total of 15 patients during the morning.

CASE STUDY PROGRESS: The client has now received 3 cycles of combination chemotherapy for her breast cancer. Her last treatment with doxorubicin, cyclophosphamide, and 5-fluorouracil was approximately 12 days ago. She came to the emergency room with a 2-day history of fever, chills, and shortness of breath. On arrival, she is disoriented and agitated. Vital signs are 86/43, 119, 28, 39.8° C, SaO2 85% on room air. Laboratory data include WBC 1.2 thou/cmm, Hct 24.9%, Hgb 8.7 g/dl, platelets 125 thou/cmm. Differential WBC count shows 37% granulocytes, 60% lymphocytes, 3% monocytes. Chem 14 is within normal limits, with the exception of BUN 28 mg/dl, creatinine 1.6 mg/dl, and lactic acid 2.4 mg/dl. Chest x-ray demonstrates diffuse infiltrates in the left lower lung.

How would Ed’s blood help protect him from a foreign invader such as the one now in his system?

Mindy Perkins is 48 year old woman who presents to the ED with 10- 15 loose, liquid stools daily for the past 2 days. She completed a course of oral Amoxicillin seven days ago for a dental infection. In addition to loose stools, she complains of lower abdominal pain that began 2 days ago as well. She has not noted any blood in the stool. She denies vomiting, fever, or chills. She is on Prednisone for Crohn’s disease as well as Pantoprazole (Protonix) for severe GERD.

S- 3671 dispatched to a m pt C/O of abdominal pain and black stool. Pt is a 49 y/o m whose C/C is abdominal and lower back pain. Pt also states that he is experiencing cramping around his left ribcage. Pt states that he has been experiencing N/V/D for the past four days. Pt also states that his bm's have produced black, watery stool since the monday prior to the incident date. Pt is able to provide EMS personnel with a detailed medical Hx that includes HIV, acid reflux, and recently diagnosed COPD. Pt also states that he recently stopped smoking cigarettes. Pt is also able to provide EMS personnel with a list of medications that he is currently taking that includes Duloxetine, Stribild, Ranitidine, Aripiprazole, oxycodone, and proair. Pt states that he has not taken any of his prescribed medications for the past four days prior to the incident date. Pt states that he has allergies to Kaletra and gabapentin. Pt states that his primary

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

Mr. .J. is a 30 year old Caucasian male presented to the Emergency Department with symptoms of myalgia, fever, rash, swollen glands, leukopenia, and thrombocytopenia. Mr. J. reported fever and sore throat started about a week ago and the rash presented today. Mr. J. stated “I thought I had the flu but I am not feeling any better and now I have a rash, that’s why I decided to come to the E.D.”. (Health and Human Services panel, 2013)

The Board office received a letter from Mary Fahey, MPHP via fax on 05/04/2015, advising that Dr. John Medley, M.D. a current “ILOD” status had informed her that he had relapsed over the weekend of April 25-26, 2015.

Physical examination showed soft, right upper quadrant tenderness with mild hepatomegaly. Ultrasound of abdomen revealed contracted gallbladder and hepatic steatosis. CT of abdomen and chest without contrast revealed bibasilar heterogeneous opacities, bilateral pleural effusions, prominent lower right paratracheal lymph node, and two hyper enhancing foci within the liver. Abdominal MRI showed liver masses. With this, medical concerned was for neutropenia fever due to viral infection vs HIV vs malignancy vs drug induced. Plan of care included, CT of the abdomen and chest, ultrasound of abdomen, MRI, blood culture, urine culture, stool analysis, peripheral smear, Infectiologist and Oncologist consultation, C differential toxins, mono spot test, A1C and TSH test, intravenous fluid of 150 cc/hr of NS, Lyrica: 25 mg, 1 cap, oral, twice a day , Zofran: 4 mg, 2 mL, IV Push, every 6 hours, Zosyn IVPB: 3.375 gram, 100 mL, 25 ml/hr, IVPB, every 8

When I initially started planning this paper I was ecstatic to learn what the literature had proven effective for the Native American community and possibly my own people, the Navajo Nation. Since I was a little girl I pledged that I was going to help my people, in any way that I could when I grew up. My main drive behind my profession of choice isn’t for the money obviously, I grew up on the Navajo Reservation, and I have witnessed first hand the detrimental effects of alcohol abuse. My father was an alcoholic he died

DOI: 11/24/2011. The patient is a 48-year-old female home health aide who sustained injury while turning a patient in bed to put a clean pad when the bed moved. Per OMNI, the patient is diagnosed with L4-5 disc herniation with annular tear and left knee radicular syndrome. She has undergone posterolateral and interbody fusion at L4-5 on 02/18/2013.

Also, I see that the SAE (Acute Upper Gastrointestinal Hemorrhage) that caused this hospitalization on was reported on 13Apr2017, but the event occurred 05Mar2017 to 14Mar2017 were you aware of this hospitalization prior to the patients week 24 visit on 12Apr2017, as SAEs need to be

Michael Martin sustained debilitating injuries as a result of an auto accident (Pozgar, 2013). He suffered severe subcortical brain damage that impaired physical and cognitive function (Pozgar, 2013). He was paralyzed on his left side, not able to speak, eat, or maintain control of bladder or bowel function (Pozgar, 2013). He was aware of his surroundings, and communicating very minimally with head nods (Pozgar, 2013). His wife and legal guardian wanted to have his food and fluids withdrawn , indicating years before the accident Michael had made statements indicating he would never want to maintained as a vegetable (Partnership for Caring, 2001).