St. Joe's Case Summary

He admits to a 25 pound weight gain over the last few months. The patient was

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.

Scenario: Mr. B, a 67-year-old-man, came to the ER complaining of severe pain to his left hip and leg after falling over his dog at home. Left leg appears shortened with swelling in his calf, bruised, and limited range of motion.Mr. B has a history of impaired glucose tolerance and prostate cancer. Home medications include atorvastatin and oxycodone for chronic back pain. Mr. B’s labs, taken during a previous visit with his primary care doctor, revealed elevated cholesterol and lipids.

PAST MEDICAL/SURGICAL HISTORY: As above. SOCIAL HISTORY: Status post heavy smoking, 50+-pack-year history. He quit 10 years ago. Status post alcohol abuse, quit 3 or 4 years ago. He lives by himself and no longer drives but has 2 daughters here in Miami who take him where he needs to go. FAMILY HISTORY: Patient’s wife died 14 years ago of COPD due to lifelong smoking. Brother has diabetes mellitus. Unremarkable family history otherwise. REVIEW OF SYSTEMS: No fever, no nausea, no vomiting. Patient has incontinence of bowel. No shortness of breath, no chest pain, no palpitations. PHYSICAL EXAMINATION: Well-developed, well-nourished white male who is alert and oriented x3. Wears bilateral hearing aids. Afebrile with blood pressure 130/70. NECK: No carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: S1, S2 normal. No murmur. No S3 or S4. ABDOMEN: Soft, nontender. No arterial bruits. No masses, no organomegaly. EXTREMITIES: No edema. No pulses present in the lower extremities. The right great toe is absent. The left great toe shows a 2 x 1 cm deep ulcer with redness around the toe with pus extruding. PLAN 1. Get consult with Dr. Beth Brian, Infectious Disease. 2. Follow up with Dr. Hirsch, Orthopedics. (Continued)

In Summary: On 08/25/2016 at 2000 hours, R/o's were dispatched to St. Anthony Hospital (2875 W 19th St, Chicago, IL 60623) in regards to a battery victim with a broken jaw that was in room number 387. Upon arrival, R/o's spoke with the victim Veraza, Rafael (M/W DOB 04/16/2000), along with his mother and father on scene.

One afternoon a 67 year-old man presented to the emergency department of a small, rural hospital complaining of severe left leg and hip pain following a fall at home. The patient had no past history of falls. He had a history of impaired glucose intolerance, prostate cancer, hypercholesterolemia and hyperlipidemia. The patient’s current medications were atorvastatin and oxycodone for chronic back pain. The patient stated his pain was ten out of ten on a scale of one to ten with ten being the worst. The left leg appeared shorter than the right, edema was present in the calf, as was ecchymosis and he had limited range of motion. After an evaluation in triage by a registered nurse and a subsequent examination by the emergency department physician, a plan was established to sedate the patient using moderation sedation protocol and perform a manual reduction of the hip.

On December 14, 2015, at approximately 8:50 AM I, Deputy Ragsdale, was dispatched to 630 County Road 4890 lot 6, Winnsboro, Texas in reference to an assault that occurred after the fact.

The patient is an 86-year-old female who was brought to the emergency room because of bilateral leg swelling. She was recently discharged from the Arbor Glen Reha and she's developed increasing bilateral leg edema. Her medical history is significant for hypothyroidism, chronic kidney disease stage II, anemia which is a chronic, ulcer in the sacral ulcer stage III and she denies any other symptoms. Review of the lab work does show a bump in her creatinine from 1.27 baseline in February of 18 to 1.54 on this admission with an increase in her BUN. She also demonstrates a mild anemia of 10 with a MCV of 90. Her edema is described as massive by the attending physician. PT examination reveals she needs significant assistance to moneuver her

Past Medical History: The patient has a history of end-stage renal disease secondary to IgA nephropathy, hypertension, alcohol abuse, biopsy proven liver cirrhosis, history of right leg cellulitis,

This is a 68-year-old gentleman who presents to the ED stating that his legs are really swollen and draining yellow stuff. It is to be noted this patient was originally placed in observation status by the attending physician. After my clinical review of the chart and discussion with him I believe this patient warrants acute inpatient hospitalization. In the ED on presentation he is found to be anemic with a hemoglobin of 8.9, hematocrit of 27.1. He is also dehydrated with specific gravity urine greater than 1030. He has a low-grade temp of 99. On his physical exam he is noted to have a 2+ bilaterally pedal edema from his feet up to his knees, as well as chronic bilateral stasis changes in his legs with erythema and increased warmth.

This is 51 year old AAM. Patient has a history of HTN and DM, his current medications are glipizide 5 mg QD and lisinopirl 5 mg QD, but hasn't been taking them for more than one week. Patient reports neuralgia, tingling and prickling sensation at his bottom of his feet. Patient is a current resident at a Group Home and unable to afford any of the medications and needs community resources. Patient also report blurred vision, denies chest pain, SOB, N/V/ D,or fever. Patient is a current tobacco user, denies use of alcohol or illicit drugs.

My patient is a 68-year-old Indian male. His health issues include hypertension, Type 2 diabetes, hyperlipidemia, cellulitis, and insomnia. He has been in the facility for 3 years. My patient’s weight is 156 lbs. and there were no major weight changes for the time he has been in the facility. My patient needs assistance with either wheelchair or a walker, is able to ambulate with or without a device. He is not allergic to anything, therefore, no modification to the medication is needed. The primary the patient is in the facility is because of a foot ulcer. The foot ulcer is unable to heal at a normal pace because he has diabetes. My patient did not take any medication prior to admission to the facility.

On 10/13/16 I met Mr. Westover at the office of Dr. Raymond. Mr. Westover ambulates with a cane. He reports when he is at home he doesn’t use it. Physical therapy continues to work with strength and balance goals. Mr. Westover feels he would benefit with another month of therapy. He has completed speech therapy. The peg tube site on Mr. Westover’s abdomen still has a scab and scant drainage at times. Dr. Raymond would like his to keep putting Neosporin on it. If it doesn’t fully close doctor would like him to follow up with gastrologist who put the tube in. Mr. Westover examination shows weakness still on the left leg, and right arm.

This patient is an 80 year old female who required inpatient hospitalization due to: She was brought by the ambulance to the Emergency Department with complaint of chest pain for the past week, worsening over the past 2 days. She also had non-productive cough, nausea, diaphoresis, shortness of breath, and bilateral inspiratory crackles with mild expiratory wheezing in her lungs, as well as one plus pitting edema on the lower extremities. Her medical histories were significant for diabetes mellitus type 2, hypertension, hyponatremia, status post for PCI or coronary artery bypass graft with pacemaker, and a recent hip fracture status post left hip replacement. In the Emergency Department, her vital signs included a blood pressure of 150/78mmhg, and a respiratory rate of 24 breaths per minute, with an oxygen saturation of 95 % on 3 Liters of oxygen per minute. She had a troponin I of 227 and BNP level of 1539 (noted as elevated). At that time, she was given aspirin to chew, sublingual nitroglycerin , 40 mg of IV Lasix, morphine, was placed on oxygen which helped with her breathing , telemetry monitoring, and EKG was done.

At today's visit he is in bed watching TV. He is awake and alert. He complains of chronic back pain that radiate to his neck. He reports that the pain is achy with a severity of 4/10. His pain is worse with movements. He is on a pain regimen of Morphine ER 30mg every 12hrs. He reports that this regimen is effective in managing his pain. He is noted to be wearing his oxygen 2L/min. He has a history of COPD. He get SOB with minimal activities. For his COPD and SOB he is uses his oxygen along with Spiriva and Ventolin 2 puffs prn. He has opiate induced constipation that is manage with Colace. He also has a comorbidities of CHF, HTN