Patient describes months of an illness with symptoms waxing and waning, that includes a cough, coughing so hard that she pees on herself sometimes. That she has pain in her chest with the cough and at times get short of breath. This morning she got extra short of breath that she was playing with a relative and that prompted this visit. She notes with it rhinorrhea, ear pain, hoarseness, inability get sputum up, nausea and vomiting, and diarrhea which alternates with constipation. She has not eaten in a week. She notes ear pain bilaterally. REVIEW OF SYSTEMS Reveals this recent illness, states that it is a pattern that she has had for some time. Does note some weakness, notes anxieties but not suicidal. Does notice the sore throat meaning …show more content…
SKIN: Exhibits no rash and is warm and dry. EXTREMITIES: Not tender. Legs are not edematous. They have good range of motion. NEUROPSYCHIATRIC: She is oriented to person, place, and time. Mood does vary somewhat and appears to be somewhat depressed, somewhat flattened, but mood does vary. EMERGENCY DEPARTMENT COURSE Offered an evaluation that included did lab work and a chest x-ray and she at first agreed to this and she did ask for a neb treatment and neb treatment was administered. She felt that it was urgent that she return home and that she felt safe and felt that she was reasonably stable and declined our offer of a chest x-ray, blood work, and urinalysis including UDS. She did also ask for Tessalon Perles. Prescription for those and a cough syrup in improvement over the Robitussin she was taking at home. While she was here she had 60 mg of pseudoephedrine administered and 200 mg of Tessalon Perles. A neb treatment was given. She is advised to seek help with her own physician and her PCP is apparently Michael Larue and she agrees to this plan. Prescription is written for Tessalon Perles 200 one t.i.d. number 15.
Dr.Bain ordered a CT scan of Cynthia’s chest to rule out a possibility of an aneurism. Dr. Bain also did another CT scan of Cynthia’s abdomen to evaluate her liver. Additional lab work and thyroid testing was done. Around 5:00pm she was discharged with instructions to follow up with her primary care physician Leah Avera, M.D within one week. In Cynthia’s discharge summary that was signed by Dr. Pesante, states, in part, "it just seems like Cynthia’s problem may have more so been either some kind of infectious process or possibly a thyroid
HPI: MR is a 70 y.o. male patient who presents to ER with constant, dull and RUQ abdominal pain onset yesterday that irradiate to the back of right shoulder. Client also c/o nauseas, vomiting and black stool x2 this morning. He reports that currently resides in an ALF; they called the ambulance after his second episodes of black stool. Pt reports he drank Pepto-Bismol yesterday evening without relief. Pt states that he never experienced similar symptoms in the past. Denies any CP, emesis, hematochezia or any other associated symptoms at this time. Client was found with past history gallbladder problems years ago.
She had a two week history of feeling generally unwell, complaining of tiredness and lethargy. She had no other significant symptoms. Her past history includes well controlled asthma and anxiety. She was a smoker of 20 cigarettes per day. She was taking amitriptyline, Symbicort (budesonide and formoterol inhaler). She had no significant family history of medical illness and had no clinical findings on examination. Blood tests showed corrected calcium of 4.22mmol/L (NR 2.20 -2.60) with suppressed paired PTH of 1.45pmol/L (NR1.60- 6.9). Her renal function was initially impaired, but normalized with rehydration. Her liver function tests, full blood count, vitamin D, myeloma screen and serum ACE levels were all within normal limits. Ultra sound scan (USS) of kidneys, USS of parathyroid and computerized tomography (CT) of thorax, abdomen and pelvis were all reported as normal with no cause found for her
I interviewed the complainant via telephone as I had made several attempts to contact her for interview but was unsuccessful. On 02/02/2015 Ms Dena Andrews was contacted and she advised that the patient was incarcerated in Vandalia at the women’s prison for theft and has been there since October 2014. Andrews stated that the main problem with the doctor was that he would not write prescriptions for potassium for the
The staff believed the patient’s altered behavior was due to the possible drug withdrawals. While the symptoms are similar, there are distinct differences between hypovolemic shock- secondary to blood loss, and acute opiate withdrawals. With a thorough exam, the staff should have been able to recognize this difference. The Clinical Opiate Withdrawal Scale, (Wesson, D. R., & Ling, W., 2003) would have been the proper objective measurement tool to be able accurately, assess the patient. Another breach of duty was not getting the CT scan down in an appropriate amount of time. The physician had a high index of suspicion that the patient was bleeding internally, yet the CT was not completed until the following morning. Lastly, the patient admitted to a substance abuse problem, yet a drug screen was not ordered. If it had been, they would have seen there were no opiates in his system and he was positive for alcohol and benzodiazepines.
getting weak and the family must understand the stress her body is under and must become a unit
listen to the every whim of her husband caused this illness to appear. Both illnesses were
Upon arrival, she reported not taking her medication for nine months. She also refused the influenza and pneumonia vaccine however they were both administered despite patient refusal.
J.P., a 58 year old female, presents to the Emergency Room on March 18th. She has a past medical history of cervical cancer, atheroembolism of the left lower extremity, fistula of the vagina, peripheral vascular disease, neuropathy, glaucoma, GERD, depression, hypertension, chronic kidney disease, and sickle cell anemia. She complains of right lower extremity pain accompanied by fatigue, a decreased appetite, increased work of breathing, burning urination, and decreased urine output for three days. Upon admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings.
A 22-year-old male presents to the ER for evaluation of recurrent nosebleeds. He reports a 6-day history of nosebleeds that occur at daily and last up to 30 minutes. Nosebleeds have been worsening. He has noticed large bruises on his abdomen and thighs recently. He has been unable to work up these past 2 days due to a fever of 102°F. He also complained of fatigue and SOB. He denies throat pain, cough, nausea, and emesis. He reports headaches and mild gum bleeding when brushing his teeth. Physical examination reveals vital signs include a temperature of 101°F, heart rate of 113, RR of 21, and BP of 131/74. The patient is pale but in no acute distress. Head, eye, ear, nose, and throat examination reveals that his oropharynx is slightly dry with
When I was working as a bedside nurse in the Emergency Department, in one of my duties I was not satisfied with the treatment plan made by a resident doctor for XYZ patient. He entered intravenous KCL (potassium chloride) for the patient. The purpose of that medication and its dose for that patient was not clear to me. I assessed patient history and came to know that a middle aged patient came with the complaint of loose bowel movements, vomiting, and generalized weakness. His GCS (Glasgow comma scale) was 15/15, looked pale but was vitally stable. I exactly do not remember about his previous disease, social or family history but I do remember that he was there with his son. According to the care plan, I inserted intravenous cannula, took blood
Patient profile: Heterosexual Muslim Woman who has been in the United Stated for three years. She came from Pakistan. She is 42 forty-two years old, from low socioeconomic standing, English language barrier, and is Muslim rituals and practices. She came to emergency department with her husband due to shortness of breathing, high fever, severe cough. She was dignosed with new onset of pneumonia and currently on antibiotic. she also has history of Vitamin D deficiencies and diabetes mellitus type II. She admitted to medical-surgical floor for observation...
The poem begins with “Thank Heaven! The crisis, The danger, is past, And the lingering illness, Is over at last.” Without any other information, the reader would naturally draw the conclusion that the speaker has been cured of a deadly sickness. However, when they continue reading
The nurse confirmed patient identification, asked subjective questions focusing on chief complaints, performed a focused assessment, obtained medication list, baseline vitals, and assessed the patient’s past medical history. She asked the patient questions such as previous hospitalization/surgery, metal implants, allergies, health history, sleep apnea, and alcohol/tobacco use. The nurse told the patient the doctor would be with her shortly. The nurse reported to the doctor regarding the patient and obtained orders for treatment from the doctor. The nurse then started an IV line and hung an IV solution bag of normal saline because the patient was experiencing abdominal pain. The nurse also administered pain medications and the patient was ready to be discharged. The nurse gave discharge instructions and made sure that the patient had a ride
The patient's condition is serious. Symptoms are multiple. His health is noxious. He has a fever, higher than ever before. Efforts to bring it down are not working. Poison has been found in body fluids. When symptoms are treated in one area, more pop up in other areas. If this were a usual patient, doctors would be inclined to declare the multiple sicknesses as chronic and terminal. Not knowing what else to do, they would just take steps to make the patient as comfortable as possible until the end came.