81 yo F admitted s/p patellar fx and sx with pin. Initial contact with pt, appears frail with loss of muscle mass. Sx wound present. Reports has not been eating well as she did not like the food at the hospital and now complains she does not like the low fat diet she is on. Unsure of any wt change. Does not follow any diet restrictions at home. Full assessment to follow. write nutrition PES statement
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81 yo F admitted s/p patellar fx and sx with pin. Initial contact with pt, appears frail with loss of muscle mass. Sx wound present. Reports has not been eating well as she did not like the food at the hospital and now complains she does not like the low fat diet she is on. Unsure of any wt change. Does not follow any diet restrictions at home. Full assessment to follow.
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- Name: Patient XOXO Age: 54 y/o Patient XOXO, a teacher at public school in Caloocan City. She currently weighs 57kg and stands 5'4'' tall with medium body frame size. She was recently diagnosed with Dysphagia secondary to Neurologic Disorder. Her doctor prescribed a Level 1 Dysphagia diet based on her tolerance after the swallowing assessment and recommendations of OT and PT. Create a one-day meal plan for Patient XOXO requiring such diet.History of present illness: Patient is a 67 year old thin Caucasian female presenting to her family practitioner with the main complaints of decreasing strength and moderate back pain that radiates from the back to the sides of the her body. Past medical history Irritable bowel disease. Right foot stress fracture last year while stepping off a small bench. Family history Father dies of a heart attack at age 80. Mother has a history of Osteoporosis. Social History Patient smoked 2 packs a week from age 25-50. Patient has a long history of alcohol use and abuse from age 20 to 45. She frequently got drunk during social occasions as well as during gatherings, as often as once a week. She stopped drinking 13 years ago. Sedentary life style Allergies None Medications Multivitamins Calcium 1200 mg/day Key Labs, images, or procedures performed in relation to current diagnosis. Bone Density: T score of -3.1 Estrogen levels: <30 pg/mL (decrease) Key Physical Examination…A 58-year-old woman presents to the emergency department with progressive fatigueand weakness for the past 6 months. She is short of breath after walking several blocks.On review of systems, she mentions mild diarrhea. She has noted intermittent numbnessand tingling of her lower extremities and a loss of balance while walking. She denies otherneurologic or cardiac symptoms and has no history of black or bloody stools or otherblood loss. On physical examination, she is tachycardic to 110 bpm; other vital signs arewithin normal limits. The head-and-neck examination is notable for pale conjunctivas anda beefy red tongue with loss of papillae. Cardiac examination shows a rapid, regularrhythm with a grade 2/6 systolic murmur at the left sternal border. Neurologicexamination reveals decreased sensation to light touch and vibration in the lowerextremities; no depression noted. The hematology consultant on call is asked to see thispatient because of a low hematocrit level. Megaloblastic anemia…
- History of present illness: Patient is a 67 year old thin Caucasian female presenting to her family practitioner with the main complaints of decreasing strength and moderate back pain that radiates from the back to the sides of the her body. Past medical history Irritable bowel disease. Right foot stress fracture last year while stepping off a small bench. Family history Father dies of a heart attack at age 80. Mother has a history of Osteoporosis. Social History Patient smoked 2 packs a week from age 25-50. Patient has a long history of alcohol use and abuse from age 20 to 45. She frequently got drunk during social occasions as well as during gatherings, as often as once a week. She stopped drinking 13 years ago. Sedentary life style Allergies None Medications Multivitamins Calcium 1200 mg/day Key Labs, images, or procedures performed in relation to current diagnosis. Bone Density: T score of -3.1 Estrogen levels: <30 pg/mL (decrease) Key Physical Examination…an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
- an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
- an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…Document the following senario using SOAPIE documentation Mr. Smith is one day post-operative (Post-up) abdominal surgery. He complains of (c/lo) "severe pain" to his abdomen and rates his pain level as an 8 on a scale of 1-10. he is grimacing. His heart rate is 92. The nurse administers morphone sulfate 4mg IV. The nurse evaluates Mr. Smith's pain after administering the morphine sulfate. Mr. Smith says his pain has decreased and now rates his pain level as a 2. HE is no longer grimacing and his heart rate is 72.