Preview

Hillcrest Medical Case 4 H&P

Powerful Essays
Open Document
Open Document
630 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Hillcrest Medical Case 4 H&P
HISTORY AND PHYSICAL EXAMINATION

Patient Name: Adela Torres

Patient ID: 132463

Date of Admission: 6/22/2013

Admitting Physician: Leon Medina, MD, Internal Medicine

Admitting Diagnoses: Stomatitis, possibly methotrexate related.
Chief Complaint: Swelling of lips causing difficulty swallowing.
HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately 2 weeks ago she developed a respiratory infection for which she received antibiotics and completed that course of antibiotics. She developed some ulcerations of her mouth and was instructed to discontinue the methotrexate approximately 10 days ago. She showed some initial improvement but over the last 3 to 5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty. Patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate. She has rather diffuse pain involving both large and small joints. This has caused her some anxiety.

MEDICATIONS: Prednisone 7.5 mg p.o. daily, estradiol 0.5 mg p.o. q.a.m., Mobic 7.5 mg p.o. daily, recently discontinued because of questionable allergic reaction, HCTZ 25 mg p.o. every other day, and oral calcium supplements. In the past she has been on penicillamine, azathioprine, and hydroxychloroquine but she has not had Azulfidine, cyclophosphamide, or chlorambucil.

ALLERGIES: None by history.

FAMILY and SOCIAL HISTORY: Noncontributory.

(Continued)

Patient Name: Adela Torres
Patient ID: 132463
Room No.: 541
Date of Admission: 6/22/2013
Page: 2

PHYSICAL EXAMINATION: This is a chronically ill appearing female, alert, oriented, and cooperative. She moves with great difficulty because of fatigue and malaise. VITAL SIGNS: Blood

You May Also Find These Documents Helpful

  • Satisfactory Essays

    Barua Patient ID: 135799 Room: CCU4 Age: 42 Sex: Male Admitting Physician: Dr. Simon Williams, MD Pulmonology Date of Admission: 01/07/2013 Admitting Diagnosis: 1) Rule out myocardial infarction 2) History of tuberculosis 3) hymoptesis 4) status: post embolectomy. Chief Complaint: tightness in chest, shortness of breath, fast heart rate. HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42-year-old gentleman from Bangladesh who presents with chest tightness, shortness of breath, and…

    • 602 Words
    • 3 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Hillcrest Case 7 H&P

    • 402 Words
    • 2 Pages

    ankle pain. DETAILS OF PRESENT ILLNESS: This is a 44 year old Hispanic male who I was kindly asked to admit by Dr. Max Hirsch. The patient is status post arthrodesis of the left ankle and has newly diagnosed diabetes and hypertension. PAST MEDICAL HISTORY: Pre-op blood glucose was noted to be greater than 200. The patent asked for a medicine consult/admission for further evaluation. Currently he denies chest pain and shortness of breath. No dysuria, or increased urinary frequency. Past…

    • 402 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Hillcrest Case 6 H&P

    • 605 Words
    • 3 Pages

    HISTORY AND PHYSICAL EXAMINATION (H&P) Patient Name: Deanna Martinez ID No.: 117232 Room No.: 425 Date of Admission: 05/26/---- Admitting Physician: Sheila Goodman, MD Neurosurgery Admitting Diagnosis: Questionable herniated disk Chief Complaint: low back pain, right leg pain. HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago…

    • 605 Words
    • 3 Pages
    Satisfactory Essays
  • Powerful Essays

    Hillcrest Medical Case 3

    • 1628 Words
    • 7 Pages

    Name: Patul Barua Patient ID: 135799 Room Number: CCU4 Date of Admission: 01/07/2010 Admitting Physician: Simon Williams, MD of Pulmonalogy Admitting Diagnosis 1: Rule out myocardial infarction 2: History of tuberculosis 3: Hemoptysis 4: Status post embolectomy Chief Complaint: Tightness in the chest, shortness of breath, fast heart rate. HISTORY OF PRESENT ILLINESS: Mr. Barua is a 42 year old gentleman from Bangladesh who presents with chest tightness, shortness of breath, and…

    • 1628 Words
    • 7 Pages
    Powerful Essays
  • Powerful Essays

    Hillcrest Medical Case 1

    • 1461 Words
    • 6 Pages

    pregnancy although she states she is sexually active and using no birth control. Gynecologic History: Patient is graved to par 1 abortus 1. her only child is a year old 15 year old daughter who lives in Texas that lives with her grandmother. PAST MEDICAL HISTORY: Positive for hepatitis B PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past, has plastic surgery on her ears child. SOCIAL HISTORY: Married, has 1 daughter, patient works as a substitute teacher, smokes 1 pack of cigarettes…

    • 1461 Words
    • 6 Pages
    Powerful Essays
  • Powerful Essays

    Hillcrest Medical Case 1

    • 669 Words
    • 3 Pages

    chance of pregnancy; although she states that she is sexually active and using no birth control. Gynecologic History: Patient is gravida 2, para1, abortus 1. Her only child is a 15 year-old daughter who lives in Texas with her grandmother. Past Medical History: Positive for Hepatitis B Past Surgical History: Pilodinal cyst removed in the remote past. Had plastic surgery on her ears as a child. Social History: Married, has one daughter. Patient works as a substitute teacher. Smokes one-pack…

    • 669 Words
    • 3 Pages
    Powerful Essays
  • Satisfactory Essays

    Hillcrest Medical Case 2

    • 1910 Words
    • 8 Pages

    RADIOLOGY REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M CT Scan No: 10-790031 Ordering Physician: Alex McClure, MD Procedure: CT scan of abdomen and pelvis without contrast. Date of Procedure: 11/14/2012 HISTORY: RLQ pain, no previous studies. ABDOMEN: The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened…

    • 1910 Words
    • 8 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Hillcrest Medical Case 6

    • 576 Words
    • 3 Pages

    HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Lydia Cruz Patient ID: DOB: Age: 40 Sex: F Hospital Number: 11723 Room No.: 425 Date of Admission/Date of Arrival: 05/26/2012 Admitting/Attending Physician: Tomas Burgos, MD Admitting Diagnosis: Questionable Herniated disk. Chief Complaint: Low back pain, right leg pain. HISTORY OF PRESENT ILLNESS: This 40-year-old black Latin female presents with complaints of low back and right…

    • 576 Words
    • 3 Pages
    Satisfactory Essays
  • Satisfactory Essays

    past. D: She had left foot surgery in the remote past at Hillcrest by Dr. Smith, myself. E: She had right hip surgery 28 years ago. F: She had left hip surgery 26 years ago. G: 17 years ago she had a stage 2 left hip procedure completed 15 years ago. H: She had left hip revision 12 years ago. I: Nine years ago she had a mass on the bottom of her foot removed by Dr. Shelton of Podiatry . SOCIAL HISTORY: She works in the medical field. Enjoys a healthy social life, lives alone, is single…

    • 1593 Words
    • 7 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Blood clots. Indications: Patient requires bronchoscopy because of recent onset hemoptysis and a remote history of tuberculosis. PROCEDURE: Patient was routinely pre-medicated with 25mg of Demerol with 2mg of Versed also used. About 4 milliliters of 4% Xylocaine was used during the procedure. The glottis, epiglottis, pseudocords, and cords were normal. Upper trachea was normal. Lower trachea and carena were normal. A few small, scattered thrombi present were easily suctioned. The right…

    • 269 Words
    • 2 Pages
    Satisfactory Essays