The patient is an 88-year-old gentleman who is brought to St. Joe's ER complaining of inability to walk. The patient 6 days ago began to having trouble walking with his walker. He reported left arm pain which radiated up his left arm. The patient had pain in the left foot. The patient was taken to St. Joseph's Hospital in Wayne. In the ER he was diagnosed with gout and begun on Colchicine. Since that time he has shown no improvement. He has become essentially chair-bound and unable to walk so he is brought to St. Joe's ER. His medical history is significant for atrial fibrillation, hypertension, hyperlipidemia, coronary artery disease and the patient also has a colostomy bag he had a procedure done and they were unable to connect is
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.
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.
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.
An attending physician statement completed by Dr. Peter Chweyah (Internal Medicine), dated 06/16/2016, indicated that the claimant presented with complaints of lower extremity weakness, neuropathy, weight loss, acute renal failure, and gout, as well as anemia. Objective findings showed an extreme weakness of the legs and pain in the feet. He also had diabetes mellitus type 2, chronic kidney disease, and hypertension. It was noted that the claimant was totally disabled from 05/30/2017 through 06/15/2017 and 05/23/2017 - 05/26/2017 secondary to gout.
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)
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
The patient, Jane Doe (pseudonym to protect patient’s privacy under HIPAA), was admitted to the hospital on May 1st for bilateral lower extremity pain. She was diagnosed with lower extremity cellulitis, a bacterial skin infection. Though the infection was in her legs and she reported pain, she could ambulate with her cane. Her background showed that she has a history of hypertension, peripheral vascular disease that led to chronic venous stasis ulcer, and obesity. She had no known drug allergies, and was full code (full resuscitation). Her progression of hospitalization showed that she had increased swelling in leg, could not tolerate ultrasound to her legs, started on vancomycin (antibiotic), and was scheduled for biopsy on her right leg. She
The patient is 66 year-old male who is brought to St. Joe's ER by BLS after being found with altered mental status at home. The patient reports he used heroin 2 days prior to admission. The patient was found by his brother hallucinatin with bladder or bowel incontinence the morning of presentation. The patient has not eating in approximately 4 days. The patient himself denies having any complaints, but he is a very poor historian. His medical history is significant for prior heroin and cocaine abuse, alcohol abuse of unknown duration, hypertension, cirrhotic liver, he has had an anterior cervical discectomy of C5-C7 with anterior compression in May of 2012 and a closed reduction of C6-C7 billateral dislocation , cholecystectomy in the
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 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,
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 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
He admits to a 25 pound weight gain over the last few months. The patient was