Descriptions: On September 21, 2016, I reviewed Mrs. S’s chart prior to meeting with her. She is an 80-year-old female who is a resident at the Artman Luthern Home. She has no known drug allergies. Her past medical history includes; thrombocytopenia, hypothyroidism, unspecified dementia with behavioral disturbances, hypertension, difficulty walking, UTI, history of a fall, and artificial openings of the urinary tract. I performed a Head to toe assessment on her, my findings for the neuro assessment included her being awake alert and oriented to person only. Her pupils were equal, round, and reactive to light, with accommodation. She is wheelchair bound with +3 range of motion in her lower extremities and +5 in her upper extremities. She wears glasses, is hard of hearing and has difficulty swallowing. Her Cardiovascular assessment included normal capillary refill < 3 seconds. No JVD and No edema or swelling. Her apical pulse was 80 beats per minute. Mucous membrane was pink and moist. Her skin was warm dry and intact. She currently has no wounds or bruises.The respiratory assessment included clear and equal breath sounds. Respirations were 16 and unlabored. Chest explains symmetrical. No secretions/ sputum. GI: abdomen soft ad non-distended, last bowel movement was on September 20, 2016. Bowel sound present in all four quadrants. Her diet consists of a mechanical soft diet. GU: foley in place , draining clear yellow urine with no pain or discharge. Her
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 author read Mrs. X’s medical notes prior to their initial consultation to afford herself the knowledge she required should she need to prescribe for her when fully qualified. It was evident from reading her medical notes that there were a few considerations to take note of before commencing any treatment, such as her medical history, drug history and allergies. Her past medical history consisted of Type 2 diabetes mellitus, which was diet controlled, hypertension, hypercholesterolaemia, neuropathy, rheumatoid arthritis and raynauds syndrome.
No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,
Susan is a 78 year old widowed lady who was admitted to a medical ward following an episode of coffee brown vomiting and breathlessness. Susan has a past medical history of chronic
A (assessment): Ms. O’Reilly’s vital signs are temperature of 37.5 C, pulse of 112, blood pressure of 102/52, and respirations of 24. Her respirations are still deep but have a regular rhythm. She has a CBS of 8.1 and regular insulin running as per orders. The lab work shows uncompensated metabolic acidosis with no hypoxia. Ms. O’Reilly’s neurological status has improved with a GSC of 13. Her dehydration is being treated with NS containing 40mEQ KCL/L running at 200ml/hr and potassium levels maintained at 4.
Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle
No scalp lesions. Dry eyes with conjunctival injection. Mild exophthalmos. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosions of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her hard and soft palette. She has difficulty opening her mouth because of pain. Tonsils not enlarged. No visible exudate. SKIN: She has some mild ecchymosis on her skin and some erythema, she has some patches but no obvious skin breakdown. She had some fissuring in the buttocks crease. PULMONARY: Clear to precussion and auscultation, bilaterally. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Soft, non-tender, protuberant, no organomegaly, and positive bowel sounds. NORALOGIC EXAME: Cranial nerves ii – xii are grossly intact, diffuse hyporeflexia. MUSCULAR SKELETAL: Erosive destructive changes in elbows, wrist, and hands consistent with rheumatoid arthritis. Has had bilateral total knee replacements with stovepipe legs and perimalledal pitting edema 1+. I feel no pulse distally in either leg. PHYCIATRIC: Patient is a little anxious about these new symptoms and there significance. We discussed her situation and I offered her psychiatric services, she refused for now.
PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia noted. No edema noted in extremities. Patient skin is cool to touch, slightly clammy. EEG shows prolonged QRS wave, with ischemic ST changes and PVCs. Chest radiograph clear.
PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia
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
On the weekend of March 11 and 12, I had the pleasure of being assigned to GJW, a 72 year old, female patient in room 41. She is a retired nurse and when I was assigned to her, she had been in the hospital for 11 days. Her concurrent health challenges include rheumatoid arthritis, obstructive sleep apnea, chronic lower back pain, chronic anemia, type II diabetes mellitus, coronary artery disease, hypertension, fibromyalgia, obesity, gastroesophageal reflux disease and dilated ascending aorta. The patient’s code status is a full code and her allergies include butazoiodine, naproxen, nalfon, chloropromozine. The reason for her admission to the orthopedic surgical ward was to do a revision of her left ankle replacement that was done last year
O): BLS assessment reveals a 35 y/o/f Pt sitting in a w/c. AOx4/GCS:15. Pupils PEARRL, HEENT clear, -JVD/TD, -CP/SOB, BBS not evaluated, Respiratory rate 16 breaths per minute, SPO2 100% on room air, BP 150/100, HR 96 beats per minute, Skin w/d. Moves extremities sluggishly. Pt claims to have a history nausea, vomiting, hypertension and received a total gastrectomy approximately 5 years ago. Pt states that she vomited twice before arrival and complains of abdominal pain that only subsides when not moving.
Allergies are among the most common inveterate case worldwide. Allergy symptoms range from making you powerless to putting you at risk for life-menacing reaction.Food allergies are defined as “ the body 's abnormal responses to harmless foods; the reactions are caused by the immune system 'sreaction to some food proteins” (thefreedictionary.difntion.com).In other words,The job of the body’s immune system is to identify and ruin germs (such as bacteria or viruses) that make you sick. A food allergy results when the immune system wrong targets a harmless food protein an allergen as menace and attacks it.
Patient also, has history of hypertension, GERD, morbid obesity, anemia, and depression. She reported that the past few months, she has been feeling very weak and overall generalized deconditioning. Her ability to care for herself including her activities of daily living (ADLs), and her basic physical needs (like bathing, grooming, ambulation, meal preparation, transportation, errands, and housekeeping), had decreased, and cannot consistently carry them out.