The patient is a sixty-seven-year-old male; he is a retired CPA and he is in for his twenty-fifth visit. The patient’s main complaint is chronic sinusitis that he has been dealing with for the last thirty years; his secondary complaint is chronic phlegm in his throat. The OPQRST was not listed, but the patient reported that he did not have spontaneous sweating, he had no thirst but could drink, and that his complaints had no effect on his sleep. The patient uses nasaclear as a preventative for the sinusitis. The patients tongue is slightly pale, slightly dusky, scalloped on the side, and the tongue has a thin white coat. The patient’s vital signs were a heart rate seventy-two, and his blood pressure was one hundred-ten over seventy. No orthopedic
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.
Generally, this is a well-developed man sitting comfortably in no acute distress. Skin is warm and dry. HEENT: Head is normocephalic, atraumatic. Pupils equal, reactive to light and accommodation. Sclerae are anicteric. Oral mucosa is moist without lesions. No JVD. No thyromegaly. Lymphatics: No cervical, supraclavicular, axillary, or inguinal adenopathy appreciated. Respiratory: Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm. Abdomen: Soft, nontender. Positive bowel sounds. Liver and spleen not palpable. Strength is 5/5 throughout. Neurological exam is
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
Vital signs are BP 113/82, pulse 83, respirations 18, O2 saturation is 99. Alert, in no acute distress. HEENT: Atraumatic. Examination of his mouth revealed a 1 cm erythroplastic lesion to the left side mid tongue, which he reports some tenderness to it during palpation. Lesion has well defined borders and its unique color it is all red.
The patient is a 72-year-old black female who presented to the ED with complaints of low blood sugar. Her son found the patient at home in bed unresponsive. The son states he checked the patient's blood sugar it was 47. The patient is on NovoLog 3 times a day and Lantus one time a day. The patient had similar symptoms in the past. The patient has a medical history of dementia. She also is known to be hypertensive, insulin-dependent diabetes and has no surgical history. It is to be noted on presentation her BP was 128/95 with a pulse of 52, respirations of 15, hypothermic with a temp of 93 and oxygenating 94% on room air. She also showed significant bradycardia. EKG at 48 beats per minute, T waves were inverted in leads 4, 5 and 6 but
Patient C.B. is a 32 –year-old African American female, G2P2 who came to clinic with complaint of burning and frequency with urination and foul odor urine that she said began four days ago.
She is 74 years old, has a height of five foot six inches, and I was unable to acquire her weight. She was experiencing pain with her hammer toes at five on the pain scale. Her appetite was well. L.F. does not experience difficulty with urination or defecation, but sometimes needs assistance with going to the bathroom. She was having shortness of breath while laying down, however does not require oxygen interventions. I did have to repeat myself while performing her head to toe assessment. L.F. does not have any hearing devices. She wears corrective glasses. Her vital signs were as follows, blood pressure was 120/90 on her left arm while sitting, radial pulse rate was 84, pulse ox was 92, respirations were 20, and her temporal temperature was 97.6 ˚ F. L.F.’s radial pulses were equal in both arms. She was able to grasp my fingers equally and strongly with both hands. Her capillary refill lasted one to two seconds. Her breath sounds were normal and clear without productive or nonproductive coughing. L.F.’s apical pulse was 75 with a normal rate and rhythm, and her aortic, pulmonic, erb’s point, tricuspid, and mitral pulses had a normal rate and rhythm. Her abdomen had a round shape and bowel sounds were present and active with a low pitch in all four quadrants. L.F.’s abdomen was soft and she denied pain. She explained that she had normal passage of bowel movements without complications. She
No known allergies, no sinus, tenderness, no epistaxis, no bleeding gums, patient has partial dentures, one dental carrier noted, tongue is slightly coated, no swelling, lumps or tenderness noted in throat,
Healthy adult male. Weight 276 which is down about 10 pounds. BP 127/81. He is not otherwise examined.
The patient is a 74-year-old gentleman who presents to the ED complaining of nausea, vomiting and intolerance of foods for a week prior to presentation. His medical history is significant for having had a AAA repaired via endovascular stent, hypercholesterolemia, hypertension, atrial fibrillation, glaucoma, rheumatoid arthritis on chronic steroids and coronary bypass grafting, hernia repair and cholecystectomy. On presentation his blood pressure was 117/86 with pulse of 72, respirations of 16, temp of 97.2 and oxygenating well on room air. It is to be noted he is 5 feet 6 inches with a weight 105 pounds with a BMI 16.8. Review of his laboratory data reveals him to have a hyperkalemic metabolic acidosis. His hemoglobin on presentation was
patient was not having any pain or significant discomfort in the area. The throat was
The patient is 79-year-old gentleman who is brought in by his family due to complaints of left sided facial droop over the past 7-10 days. He also complained of difficulty swallowing due to pocketing of food on the left side of his mouth. There are no complains of weakness, loss of consciousness or syncope. The patient is also complaining of incontinence occasionally. The patient admits to having difficulty ambulating secondary bilateral lower extremity pain and swelling. The patient was recently in the hospital from April 6 to April the 9th with hypertensive emergency which placed in congestive heart failure. He also has some hearing loss. It is noted that he is noncompliant with medications at home. He walks with a walker at baseline.
PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.
The patient was a female, 95 years of age. In the beginning of July 2013, she frequently choked during a meal and we examined her with deglutition endoscope.
Sinus infections are a common condition that affects many Americans. Often times, people pass off a stuffy nose as a cold, but when they persist for weeks, you may have a sinus infection. Sinus infections are typically caused by allergies, infection, or from irritation of the sinuses due to particulate or chemicals. There are two forms of sinus infections, acute and chronic. An acute sinus infection only lasts for a short duration of time. While a chronic sinus infections can recur or last for weeks.