Essay PreviewMore ↓
PAST MEDICAL HISTORY: Unremarkable.
PAST SURGICAL HISTORY: Remarkable for tubal ligation.
SHE HAS NO KNOWN DRUG ALLERGIES.
MEDICINES ON ADMISSION: Indocin 25-50 mg p.o. q.8 hours and Anaprax 270 mg p.o. b.i.d.
The patient drinks alcohol only rarely and smokes regularly.
PHYSICAL EXAMINATION: Weight of 231 pounds, temperature 98.6, heartrate 60, respiratory rate 24, blood pressure 110/70. HEENT examination was unremarkable. The neck was supple without masses, adenopathy or bruits. The lungs showed small diffuse wheezes, but was otherwise without abnormality. Cardiovascular examination revealed a regular rate and rhythm, normal S1 and S2. Questionably slight change in the S1 with the __ maneuver and a questionable 1/6 systolic ejection murmur heard best at the lower sternal border. The abdomen was obese, showed bowel sounds in all quadrants, soft and nontender. It was difficult to tell if there was organomegaly. Extremities showed no clubbing, cyanosis or edema. Neurologically, the patient was normal.
LABORATORY DATA: Show a white count of 8, hemoglobin 14.5, hematocrit 42.5, platelets 326,000, sodium 139, potassium 4.9, chloride 104, CO2 26, glucose 105, creatinine 0.8 and BUN of 17. Please see consolidated lab flow sheet for lab data regarding this patient.
HOSPITAL COURSE: Patient was admitted in ____ evaluations as well as consultation from pulmonology service. Pulmonology service recommended the patient undergo bronchoscopy which was performed.
How to Cite this Page
"Patient Report." 123HelpMe.com. 27 Feb 2020
Need Writing Help?
Get feedback on grammar, clarity, concision and logic instantly.Check your paper »
- FINDINGS: Severe right-sided chest pain. The __ reported a friction rub. A PM lateral showed questionable mediastinal adenopathy. The patient had no cough or sputum production of ___. CT scan in ___ showed a possibility of a 1x2 cm right paratrachial lymphnode. Several smaller anteromediastinal lymphnodes which were all less than 1 cm were also evaluated. The patient was treated with Indocen with relief of her chest pain. ___ level was 64.5 with a ___ 50. PPD was negative, controls were positive.... [tags: Medical Report]
616 words (1.8 pages)
- A treadmill stress test for atypical chest pain demonstrated inferior wall ischemia. Cardiac catheter demonstrated patent graphs and left ventricular ejection fraction of 68%. Treadmill stress test felt to be false positive; however, patient did have 5 beats of ventricular tachycardia. Holter demonstrated 3 beats of multifocal ventricular tachycardia. The patient was placed on Cardizem and atypical chest pain resolved. The patient complained of periods of "difficulty breathing", especially when he awakened at night to urinate.... [tags: Medical Report]
542 words (1.5 pages)
- When working in the surgery suites, one soon learns to be hyperaware of ones surroundings. As a radiographer, one is capable of disturbing many things such as: foley catheters, IV poles, and overhead lights. One of the primary issues radiographers, and other members of the healthcare team, experience is contaminating the sterile field. Often half the OR suite seems to be covered in sterile fields and draping, and it is among the utmost importance to keep it sterile for the health of the patient.... [tags: Patient, Physician, Report, Illness]
709 words (2 pages)
- A 22 year old healthy, immunocompetent female with no past medical history underwent an arthroscopic knee surgery for a left anterior cruciate ligament and left lateral meniscal tears following a sport related injury. She had a reconstruction with hamstring auto graft from the same leg and a partial meniscectomy. 3 months after the surgery, she developed 2 areas of erythema, swelling, and pain around the harvest incision site with small abscess formation which was draining purulent discharge. She was afebrile with no systemic symptoms.... [tags: Medicine]
971 words (2.8 pages)
- Michael was seen in the Neonatal Followup Clinic on November 14, 2013 at 4 months 11 days corrected age. As you may recall, Michael was born at 32 + 2 weeks gestational age with a birth weight of 1600 grams. His neonatal course was complicated by respiratory distress and CPAP for 8 days. He had some hyperbilirubinemia and rule out sepsis. There were issues with IV access and he was on TPN for 12 days and required a PICC line. He had cellulitis and excoriation of the right arm which resolved quickly.... [tags: hospital, diet, physical, infant, growth]
626 words (1.8 pages)
- Measurement The researcher used a survey that consisted of “17 terms dealing with the following nurse behaviors: treating the patient kindly and with respect, listening to the patient, informing the patient about their care, teaching so that the patient could understand working with other nurses, passing along information from shift to shift, including the patient in report discussions and keeping the patient’s health information private” (Sand-Jecklin & Sherman, 2014). The survey used a Likert-type response for each item, with five indicating excellent care and one indicating poor care.... [tags: Patient, Nursing, Nurse, Report]
1052 words (3 pages)
Tibial Osteomyelitis Caused by Gordonia Bronchialis in an Immunocompetent Patient: A Case Report and Review of Literature
- Case Report: A 22 year old healthy, immunocompetent female with no past medical history underwent an arthroscopic knee surgery for a left anterior cruciate ligament and left lateral meniscal tears following a sport related injury. She had reconstruction with hamstring auto graft from the same leg and a partial meniscectomy. 3 months after the surgery, she developed 2 areas of erythema, swelling, and pain around the harvest incision site with small abscess formation which was draining small amounts of purulent fluid.... [tags: Case Study]
1195 words (3.4 pages)
- There have been numerous studies and reports released through the years indicating that inadequate dissemination of information among healthcare providers is detrimental to patient safety. In the acute care setting, the exchange of vital patient information between nurses is endorsed through a shift report; which typically takes place at the nurse’s station. There are many threats to patient safety that could be linked to the process of poor hand off reporting and communication. Normally, a significant amount of communication takes place during nursing handoff.... [tags: Patient, Health care, Better, Report]
1176 words (3.4 pages)
- Introduction: The term “Fibrous pseudotumor” is generally referred to a group of benign lesions arising as a result of reactive changes in testicular tunics. The condition is also known as inflammatory pseudotumor, proliferative funniculitis, chronic proliferative periorchitis, fibrous mesothelioma and reactive periorchitis (1,2). The prevalence of this tumor is so rare and most often it shows itself as painless scrotal masses associated with hydrocele or a history of trauma or infection, the usual site of involvement is tunica vaginalis but in some rare cases it can arise from tunica albuginea, epididymis and spermatic cord as well.... [tags: Medical Case Report]
977 words (2.8 pages)
- Incident Report Sentinel Events and Root Cause Analysis As a health-care professional, it is understood that the health and well being of a patient is top priority. The dedication to provide care and protection to each patient is ingrained into the very basics of nursing education. However, despite this commitment, medical errors that adversely affect the lives of patients are made everyday worldwide. These types of events are referred to as Sentinel Events. When such an event occurs, there is a need for an immediate investigation and response.... [tags: Hospital, Patient, Hospital accreditation]
767 words (2.2 pages)
2. Tobacco abuse.
4. Ovarian cyst.
Saturation study: No complications.
1. Indocin 25 mg p.o. t.i.d.
DISPOSITION: The patient is discharged to ____ to return to the care of her primary physician and to begin smoking cessation and weight reduction programs which will benefit her pulmonary status.