She was diagnosed at that time with a herniated disk and did have steroid injections and was out of work for six months. She tells me since then symptoms have come and gone, but this was the worst case of it she has had for quite some time. She was given both Percocet as well as Valium in the Exeter Hospital Emergency Room and does tell me she took these and completed them. She currently is just taking ibuprofen. Overall, her symptoms are improving.
DOI: 4/24/2015. Patient is a 40-year-old female ophthalmic assistant who sustained a work-related injury to her low back and bilateral forearms from catching a falling cart. Per ONI entry, she was diagnosed with scoliosis, work aggravated. She is status post right shoulder arthroscopic acromioplasty and distal claviculectomy on 5/13/16. Urine drug screen obtained on 10/06/16 showed positive for tramadol.
Acute Respiratory Failure This case study of 211A will contain the basic conditioning factors, expected signs and symptoms of primary medical diagnosis, nursing diagnosis, plan of care, the medications, and the overall expectation of 211A. BASIC CONDITIONIG FACTORS 211A is a 63year old female who was admitted to Providence Little Company of Mary sub-acute unit on September 30,2016. The admitting diagnosis was Acute Respiratory Failure, Cardio Vascular Accident, and Pneumonia. She has a history of Intracranial hemorrhage, Acute Encephalopathy, Hepatocellular, Urinary Tract Infection, Anemia, Gastroesophageal Reflux Disease, Seizures, and Contractures. 211A is alert and oriented to name, place, and date of birth.
He was given a prescription for Voltaren gel 1% 3-100 mg with 3 refills, to be applied 2 grams to the area, 4 times daily. Treatment plan includes ice/heat application to areas of discomfort as needed, home exercise program (HEP), over-the-counter nonsteroidal anti-inflammatory and analgesics as neded, PT to the right elbow 2 time s a week for 6 weeks, platelet rich plasma injection for the right epicondyle with ultrasound guidance for needle placement, as the patient has failed bracing and 1st cortisone injection. Patient will follow-up in 4 weeks. Per verification from the provider’s office, they are only requesting for a platelet rich plasma kit, not an injection. Current request is for This is 1 out of 4
Jacquline is a 25yo, G3 P2002, who is currently 28 weeks 3 days. She is being followed through our office due to a notable history of postpartum cardiomyopathy. She had an ECHO at the beginning of pregnancy and a repeat ECHO which was 5 days ago that also showed an ejection fraction of 60%. She has some shortness of breath which is likely related to pregnancy and her difficulty ambulating secondary to left foot surgery. Essentially, she had a clubfoot that had difficulty healing and required several reconstructive surgeries.
Subjective CC/HPI: Patient is a 26 year-old female who presents with frequent shortness of breath and wheezing. She reports experiencing shortness of breath 4 times a week and experiences nighttime awakenings twice a month due to her symptoms. Patient claims to use her Flovent inhaler one puff twice a day, less than her prescribed dose due to cost issues, and her rescue inhaler 3 times a week for when her wheezing is severe. Patient also presented with a persistent runny nose and itchy eyes starting 5 weeks prior. Her inhaler technique was assessed and deemed correct.
Treating a Patient with Rhabdomyolysis N.T., a 72 year old female with a past medical history of hypertension, COPD hyperlipidemia, and hip surgery was diagnosed with rhabdomyolysis after the patient made a visit to the ER several days following a severe fall. A CMP was ordered which revealed elevated glucose, creatinine, BUN, CO2, and AST values. Also noted were decreased potassium and ALB values as well as severely elevated creatinine kinase levels. Pathophysiology Rhabdomyolysis is described as the breakdown of muscle tissue as a result of major muscle trauma. This muscle injury can occur due to excessive overworking of the muscles or from direct trauma.
Based on the progress report dated 03/21/16, the patient reports that his low back pain tweaked again, after making the bed. He went to the emergency room last week and was provided with Toradol injection. He was told it was sciatica on the right leg. Now, it is in the center of the back and sacroiliac area. Current pain level is 8/10 with pain medications.
My selected patient was a 22-year-old lady, Emma (pseudonym), who came to see me at the outpatient clinic for the follow-up appointment about her psoriasis. She had been diagnosed and treated as mild psoriasis for 10 years with a moderate response. Although her lesions were mainly limited to upper and lower limbs, her lesions often flared up, due to physical trauma and stress. Additionally, she was very self-conscious about her psoriasis and would like to discuss the referral to a dermatologist for further treatments. Emma was chosen for a discussion as a part of a monthly conference of the