** Comprehensive Medical Report** **Patient Information:** - Name: Amelia Rodriguez - Age: 22 - Gender: Female - Date of Birth: December 31st, 2001 - Date of Evaluation: 4/1/2024 - Medical Record Number: MRN093467991. **Chief Complaint:** The patient presents with acute abdominal pain localized in the lower right quadrant. **History of Present Illness:** Amelia Rodriguez, a 22-year-old female, presents to the emergency department with complaints of sudden-onset abdominal pain. The pain began approximately 12 hours ago and has progressively worsened. The pain is localized to the lower right quadrant of the abdomen and is described as sharp and constant. The patient denies any associated symptoms such as nausea, vomiting, fever, or changes …show more content…
Family History:** No significant family history of gastrointestinal disorders or surgical interventions reported. **Social History:** The patient denies smoking, alcohol, or illicit drug use. The patient's occupation involves occupation, and there is no significant exposure to environmental hazards. **Physical Examination:** - Vital Signs: - Blood Pressure: [mmHg] - Heart Rate: [bpm] - Respiratory Rate: [breaths/min] - Temperature: [°C/°F] - General: The patient appears uncomfortable due to pain but is alert and oriented. Abdominal Examination: There is tenderness and guarding in the lower right quadrant. Rebound tenderness is elicited. No palpable masses or organomegaly appreciated. Bowel sounds are present in all quadrants. **Diagnostic Evaluation:** 1 - 1. Complete Blood Count (CBC): - WBC: [normal/high] - Neutrophils: [normal/high] - Other parameters within normal limits. 2. What is the difference between a'smart' and a'smart'? Urinalysis: Within normal limits, ruling out urinary tract infections. 3. What is the difference between a'smart' and a'smart'? Abdominal Ultrasound: Findings consistent with acute appendicitis, including a dilated appendix with wall thickening and peri-appendiceal fluid …show more content…
2021. The. Acute Appendicitis. ACS Surgery Principles and Practice. WebMD.com - WebMD.com - WebMD.com - WebMD.com - WebMD.com - WebMD.com - Web [Link] - Bhangu, A., & Sreide, K. (2017). Diagnosing Appendicitis: Challenges and Opportunities. British Journal of Surgery, 104(1), 7–8. [Link] - Fitzmaurice, G. J., & McWilliams, B. (2020) - The 'Secondary' of the 'Secondary' of the 'Secondary' of the Appendicitis. In StatPearls [Internet] -. StatPearls Publishing. [Link] - Gorter, R. R., et al. (2018). The 'Secondary' of the 'Secondary' of the 'Secondary' of the 'Se Diagnosis and Management of Acute Appendicitis. EAES consensus development conference 2015. Surgical Endoscopy, 32(3), 1097–1113.
Examination revealed an oxygen saturation of 98% and blood pressure of 145/90. Oropharyngeal inspection revealed significant crowding (Mallampati class 3) with macroglossia. Chest auscultation was clear and two heart sounds were audible with nil else.
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.
The guidelines’ first focus is the definition of sepsis, which makes sense, because there is no way to effectively treat sepsis without an accurate and categorical definition of the term. The guidelines define sepsis as “the presence (probable or documented) of infection together with systemic manifestations of infection”. Such systemic manifestations can include fever, tachypnea, AMS, WBC >12k, among others; these manifestations are listed in full in Table 1 of the guidelines. The definition for severe sepsis builds on to the definition of sepsis, bringing organ dysfunction and tissue hypoperfusion (oliguria, hypotension, elevated lactate) into the picture; full diagnostic criteria is listed in Table 2. The guidelines recommend that all
Client reports she is not currently taking any prescribed or over the counter medications. She reports she drinks alcohol and smokes marijuana daily. Client stated smokes cigarettes but when she was young she hated the smell because her step-grandfather smokes in the house.
•The forty five year old patient is diagnosed with the progressive cirrhosis inflaming the liver along with the parenchymal cells. The plain symptoms is manifested primarily because of the augmentation of edema internally in the lower abdomen.
What? The patient is 65-year-old man Mr. John Douglas who is suffering from dysphagia and have been admitted to the surgical ward for insertion of a percutaneous endoscopic gastrostomy (PEG). Apart from that, he is a Type 1 diabetes patient and has weakness in his right leg and arm because of right-sided hemiplegia. He is thin in appearance and has stage 1 pressure sore on his right heel.
During my morning rounds I began my assessment of Mrs. M., and I noted that she had shortness of breath and she was making gurgling sounds. I immediately auscultated her lungs and noted bilateral wheezing throughout all fields, her heart was irregular and rapid and she had 2plus pitting pedal edema. I noticed she had an IV running at 125ml/hr, which I quickly stopped. The patient did not have orders for IV fluid there was only an order to KVO. I raised the head of the bed and paged respiratory to the floor.
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 on urination, and decreased urine output for three days.
General: Patient is alert, oriented, not in acute distress. Not in labored breathing. Gait is non-antalgic. Cooperative and talkative mood affect. On exam of left knee inspection noticed some swelling compared with the right. Tenderness and swelling in left knee medial aspect. The scar from anterior knee is well healed. No sign of infection. Vascular exam is normal, dorsalis pedis pulses posterior, tibial pulses and capillary refill. Neurologic exam is within normal limits. Sensation and motor is intact. Motor and sensory are intact equal bilaterally. Hyperextension and flexion is within normal limits. Lachman test is negative. Knee anterior drawer test is negative. McIntosh test is negative. Inspection is no ecchymosis but there is a mild swelling in the medial
Douglas Anthony in one of the hospital in Orlando Florida on July, 2015 this patient brought to the hospital. Patient was having severe pain in the upper part of the body and was crying in the waiting room. Receptionist and other hospital members were busy in dealing with other patients. Mr. Douglas had to wait for long time to get register in electronic record of the hospital. He was sent to the emergency room where doctor examined him for stomach pain. While checking Mr. Douglas Doctor asked him about the medical history of the stomach pain. Due to language and communication problem doctor referred him to physician with his case history. Physician checked him and send him for the Lab tests. After reading the test reports physician diagnosed him for cardiovascular
According to the Primary Treating Physician’s Progress Report (PR-2) dated 8/22/2017, the patient complained of a left knee pain described as constant, aching and moderate. The pain was associated with
Dryden-Edwards, Roxanne MD, Conrad Stöppler, Melissa MD. Medicine net Inc. 17 June 2009. 23 February 2010 .
Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit.
This was his second episode since 10 days ago where he develop the same pain at his right flank. He suddenly experienced severe pain 8 hours before admission when the pain shifts to his right lower quadrant of his abdomen. The onset is at 6.30 am before worsening at 10 p.m to 2 p.m. He described the pain as continuous sharp pain and gradually increased in severity. There is no radiation of the pain. The pain was exaggerated on movement and touch. There were no relieving factor and he scale the severity as 7/10. He experienced fever for 1 day prior to admission. It was a mild grade continuous fever. He does not experienced chills and rigor. The patient does not experience any nausea or vomiting, no dysphagia, no pain during micturition and no alteration in bowel habit. He experienced loss of appetite but not notice any weight loss.
The patient has high temperature-sign of fever, a very fast pulse rate (tachycardia), and chest wheezing when listened to using a stethoscope (Harries, Maher, & Graham, 2004, p.