Source And Reliability : Patient Alert And Oriented At Time, Place And Person, Reliable Historian Essay

HISTORY OF PRESENT ILLNESS: This 46-year-old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis, presents to the emergency room after having had three days of abdominal pain. It initially started three days ago and was a generalized vague abdominal complaint. Earlier this morning, the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o. earlier around

He was able to tolerate PO earlier around 6am. but now denies having an appetite. Patient had very small bowel movement earlier this morning that was not normal for him. He has not passes has the morning. 'he is voiding well. Denies fevers, chills or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy.

HISTORY OF PRESENT ILLNESS: This 46-year old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis presents to the emergency room after having had 3 days of abdominal pain. It initially started 3 days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o earlier around 6am, but he now

T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips

History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and

The patient complained of right lower quadrant pain and of feeling faint. Dr. O'Donnel documented a chief complaint, a brief history of present illness, and a systemic review of the gastrointestinal system and respiratory system. Dr. O'Donnel also documented a complete examination of all body systems, which included all required elements. Medical decision making was of moderate complexity.

History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and

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

0900 Pt in her room lying on her bed with watching TV. Good appetite this morning, Ate 100% of her breakfast. Alert and oriented x 4 and follow commands. Vital sign T96.9, P 72, R 18, BP 113/61, O2 Sat 97 RA. Pt complained pain on her back and rate 6/10 on scale of 0 to 10. skin warm to touch and redness on the area. Lung sound clear and even to auscultated in all lobes. Breath sound regular and even. S1 and S2 auscultated. Abdominal sound presents and actives in all four quadrants. ABD soft, non-tender, no distended to palpate. Pt denied ABD pain. Pt stated last bowel movement yesterday night, medium, soft and formed. Call light within her reach, nonskid socks on, bed in down position. Will continued to monitor……………………….L.Gotora PNS2/WATC

Per medical report dated 11/24/15 by Dr. Cano, the patient is complaining of severe numbness in the right hand, tightness around the right worse than left hand. She also associates this with dropping items. She is unable to button her shirts or raise her arms up to her elbows. This is continuous all day long. Also, associated is severe low back pain with numbness, radiation, and muscle spasm in the thoracic area, and numbness and radiation down the right sciatic nerve with severe low back pain. She continued to work, sixteen-hour shifts, seven days a week. At this time, she is unable to function. She states that she has had 24 sessions of physical therapy that has definitely helped her.

The patient states she feels as though her abdominal pain after full workup by the gastroenterologist, is likely related to muscular symptoms. She does state there are certain ways she can move, that she will get the pain.

Thus allowing me to form a differential diagnosis and rule out certain causes, such as; constipation, and indigestion. Subsequently, the physical examination enabled me to confirm a diagnosis of acute abdomen. As the patient was not experiencing any worrying (red flag) symptoms associated with abdominal emergencies, such as; appendicitis or pancreatitis. However, I did forget certain aspects of the physical examination and had to be prompted by the MO. Although with more practice such incidence would be reduced.

Melissa Johnson is a 45-year-old woman who today was seen on an emergency basis when she called the office complaining of left upper quadrant pain. The patient stated that the pain has been increasing for about three months. The patient’s most notable symptom is increased belching. The patient also experiences heart burn, increased satiety, and intermittent left upper quadrant pain. The patient denies any vomiting, change in bowel habits, melena, or dysphagia. She also denies having chills, fever or rigors. The patient states that she has not been examining her sugars, and she has not felt any chest pain with exertion or dyspnea. In addition, the patient denies any orthopnea, pedal edema, or paroxysmal nocturnal

DS is a 57-year-old white female whit a history of diverticulitis who presents to the clinic for an evaluation of abdominal pain. She stated that she began experiencing left lower quadrant pain last night that worsened through the night and into this morning. The pain is described as dull, occasionally cramping, rated 7/10 in severity. The patient also stated that this pain is similar to previous episodes of diverticulitis. The patient stated that she took Gas-X this morning with little relief. She was able to move her bowels yesterday and this morning, both reportedly normal. The patient denied any fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, melena, hematochezia, or any other symptoms. At this time, there were

Musculoskeletal- erosive destructive changes in the elbows, wrist, and hands consistent with rheumatoid arthritis, has bilateral total knee replacements with stovepipe legs and perimalleolar pitting edema 1+. I feel no pluses distally in either leg.