PATIENT NAME- Smith, Robin
DATE OF ADMISSION- September 25, 2010
History Of Present Illness- The patient is a 61 year old female. The patient is complaining that they feel weak, their urine is dark, nausea, and they have Jaundice.
Past Medical History- Mrs. Smith has suffered from seizures since she was 18 years old. She has been taking Dilantin to help keep the seizures under control. No other past medical history.
Physical Examination- Temperature is 99.2, pulse rate is at 80, blood pressure 120/85. Mrs. Smith has Jaundice in both eyes. Patient’s abdomen is swollen.
Laboratory Data- Labs drawn in emergency room and it showed patient does not have Viral Hepatitis, or Cirrhosis.
Impression- Chronic Liver Disease
Discussion- A discussion was carried out with the patient on starting a healthy diet and getting proper rest. Prescribed antibiotics for the infection, steroids for the inflammation and diuretics to reduce fluid backup.
(1)-Do you think taking the Dilantin over the years caused the Liver Disease?
(2).Do you think this patient will have to worry about deterioration of brain function?
PATIENT NAME- Ross Jim
DATE OF ADMISSION- December 12, 2008
History of present illness- The patient is a 66 year old male complaining of chest pains, coughing up blood, running a fever, fatigue, and real bad cough.
Past Medical History- The patient has worked outdoors for over 40 years and, has smoked two packs of cigarettes a day. The patient was, diagnosed with an Ulcer 10years ago.
Physical Examination- Patient is running a temperature of 102. The patient was expectoration, and hemoptysis. The patient was also bradypnen. The breathing was seven breaths pre minute.
Laboratory Data- The patient was given an x-ray and an CT scan.
Impression- Lung Cancer and Pneumonia
References: www.chronicliver.com www.mayoclinic.com