HISTORY AND PHYSICAL EXAMINATION Patient Name: Chapman Robert Kinsey Patient ID: 110589 Date of Admission: 23 February ---Page 2
MEDICATIONS: Warfarin or Coumadin,
HISTORY: The patient is a 53-year-old black individual, who has had diabetes for at least six months, but thinks it has been longer than that. He has had a foot ulcer since January.…
At today's visit, she is found sitting in her wheelchair at Tiffany hall SNF. She is pleasantly confused. The facility staff reports that she was recently treated with ABT for new onset UTI. The staff reports that she continues to be follow by Vohra wound specialist for a chronic venous stasis ulcer that she has on her RLE. She has had this wound for a duration of 102 days. Her wound is dress by facility staff with xeroform dressing. She reports…
FAMILY HISTORY: The patient was adopted and does not know her family history. She lives with her husband; she has one son living and well who is in the military.…
Jessica McGowan HIM 2330 – Shaw July 2, 2014 Reimbursement Assignment and Case Mix Case #1 Female 66yo 01-Home ICD-9-CM Code Code Description Principal Diagnosis 682.7 Cellulitis, left foot Secondary Diagnosis 892.1 Infected dog bite 041.10 Staph infection E906.0 External cause: dog bite Principal Procedure 86.22 Wound debridement, foot Total Charges $6,245.10 DRG: 0572, SKIN DEBRIDEMENT W/O CC/MCC DRG Wt. 01.0077____ Full Update Hospital Reimbursement___$5,064.79__________ Reduced Update Hospital Reimbursement__$4,762.49…
The patient , whom I will call Sue, presented in the walk-in Surgery and told me she had had three days of stinging pain on passing urine, increased frequency of passing water and intermittent low abdominal discomfort. She also said that she had a water infection three months previously and that she thought that she now had the same problem. She had tried over the counter (OTC) medications and had increased the amount of fluids she drank with little effect. She said that her abdominal pain reduced after taking paracetamol but reoccurred after a few hours. She requested a prescription of the same antibiotics she had last time she had this problem.…
Pt. has a stage two sacral ulcer and a healing stage two ulcer on left ankle. Duaderm is intact and no sign of drainage noted.…
Painful Erythema, Oedema, Oral Ulcers are present. Patient only able to ingest liquids or may require IV hydration…
11/16/15 Progress note indicated that the patient has constant pain. He has burning, stabbing pain in the right lateral elbow. He has difficulty in making a full fist. It takes a long time to release with the use of hot water, if he does make a fist. The pain radiates from his shoulder down to his right thumb, index and middle fingers. Pushing, pulling, reaching and turning doorknob aggravate the pain. Pain medications…
The clinical manifestations Ms. G presents with are the round, yellow-red, 2 cm open wound on her left lower leg that has a moderate amount of thick yellow drainage; she has pain in the leg and is unable to bear weight on the leg. She has a fever and chills which are symptoms of an infection. First and foremost a history, physical and medicine reconciliation should be performed. It is important to know what medications the patient is on and has been taking, what risk factors she has, and what other medical conditions she may be battling. The labs show an elevated white blood cell…
MEDICATIONS: Prednisone 7.5 mg Po daily, estradiol 0.5 mg Po QAM, Mobic 7.5 mg Po daily recently discontinued because of questionable allergic reaction, HCTZ 25 mg Po 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.…
Patient 1-Patient now complains of nausea and is experiencing intermittent vomiting. Patient is extremely fatigued and dizzy and blood pressure is rising. Patient 2- Oxygen saturation has decreased slightly as the patient noted increased difficulty breathing. Supplemental oxygen was administered. Patient complains of a tingling and weakness in the hands, feet, legs, and arms. Patient has difficulty swallowing and requires a feeding tube.…
The patient was transported from home by her daughter-n-law. According to patient daughter-n-law she has been complaining of pains in her right leg approximately one day. Family administered daily pain medications that did not help the condition of her persisting pain. After pain persisted daughter in law later brought the patient in to the emergency room for examination.…
He was admitted to Flushing Hospital on 12/18/2016 with primary diagnoses of Infected Left Toe, Cellulitis, LT LE and RUE Gangrene, Osteomyelitis, and secondary diagnoses of S/P Partial 4th & 5th Ray Amputation, LLE Angioplasty, S/P RUE Angioplasty, ESRD ON HD ~ RT AVF – M/W/F, PAD/PVD S/P RT BKA W Prosthetic, HTN, DM W Neuropathy, and HLD. Resident is alert and oriented x3 and able to make all needs known. Resident uses a wheelchair to ambulate.…
Hack, A. (2003) Leg ulcers wounds - taking the patient 's perspective into account. Journal of Wound Care; 12: 8, 319-321.…
HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42 year old from Bangladesh who presents with chest tightness, shortness of breath, and tachycardia. Dr. J.K. McClain of cardiology is evaluating his heart condition. The patient has had the resent onset of hemoptysis. He was treated for TB in Bangladesh 15 years ago. This has prompted the concern of whether his treatment for TB was adequate or whether there is another cause for his hemoptysis. The duration of his TB treatment was apparently adequate, according to his wife. But no records are available. In addition, the patient had thrombosis of the auxiliary artery treated last year at Hill Crest. He had an embolectomy and has been on Coumadin since. INR is significantly elevated at 16. Nonetheless, because of the cavitary lesions that are seen in the right and left upper lobes, the possibility of TB has been raised. Ancillary history was given by the patients wife Nepor, with the patient translating for her from the Hindu language.…