Bp Case Map

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

The patient has no family history of heart disease or diabetes, however both her parents are on medication for high blood pressure. Her paternal grandmother died of breast cancer at age 47. Her maternal grandmother

The patient was a female on her 80s who was admitted to the hospital because of the COPD exacerbation. She had a history of stroke with minor residual effects, smoking, hypertension, and schizoaffective disorder - a chronic mental condition that is manifested mainly by the symptoms of schizophrenia, such as hallucinations or delusions, and mood disorder symptoms like manic or depressive episodes (NAMI, 2017). Patient length of stay was more than 300 days. She had two daughters who visited her everyday.

PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.

Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Symmetric chest expansion. Breathing nonlabored. Diminished breath sounds in all lung fields. Resonant to percussion.

This is 36 year old whte female. Patietn is complaining of severe earache 9/10. Patient reports she was seen at St.Vincent ED yeasterday, but didn't get treated and was told to take ibuprophen and flushout the ear with OTC. The patiet is tearful, and scared. Patietn also reports alll of her current Rx been out for past 2 weeks and haven't been taking any of her Rx. Patient denies chest pain, SOB, N.V/ D, or fever. Patient reports depressive moods, but denies thoughts of suicide or homicide.

This 54 year ld AAM. Patient has a history o fDM, HTN, and hyperlipidemia. Patient's current medications are Glipizide 10 mg BID, ASA 81 mg QD, Triamtereine /HCTZ 75/50 mg, Pravastatin 40 mg QHS, and lorsatan 300 mg QD. Patient states he is taking all mthe medications as prescribed, and he thought he was doing fine. Patient states no one in the Federal Prison System had checked his A1C in several years. The patient's A1C today is greather than 14 %. Patient denies buller vision, headache, chest pain, SOB, N/V/D, or fever. The patient denies decreased sensation of his feet, increased thirst or urination. Patient denies any depressive moods. The patient is here with his wife and had a long disussion with the plan of care for his DM, HTN, and

Pulse rate is at 72. The blood pressure was 140 / 95,which is suggestive of high blood pressure and related to his medical history. No heart murmur was noted, and no other abnormalities were noted.

7. A 56-year-old patient who has no previous history of hypertension or other health problems

Medications: Risperdal 05mg TID, BID Melatonin 6mg HS and PRN Vistaril 25-50mg ER Visit: None

The following case scenario is based on a fictitious patient, and it would be use on this paper as a guidance to develop a patient and family teaching plan. The situation: Mrs. Marquez, a 39-year-old Caucasian female was admitted into the Emergency Department due to complains of shortness of breath and anxiety. Patient cannot take deep breaths, appears overweight and denies Allergies to medication. The background: Patient has medical history for panic attacks, atrial fibrillation, and Grand Mal seizures; however, patient is not constantly taking her seizure medication. Patient previously had a cholecystectomy, and smokes 1 pack of cigarettes per day for 12 years. The Assessment: Patient vital signs 98.8° F oral, 109 heart rate, 26 respiratory rate, 150/86 blood pressure, SaO2 97% on room air. Denies pain. Neurological; Patient is 65 inches tall, weighing 246 lbs. She is able to move all extremities with strong pushes and pulls. States her “last seizure was two months ago.” Respiratory; Respirations are even, deep, and rapid. Lungs are clear on auscultation. Cardiac; EKG reveals atrial fibrillation; patient states, “It feels like my heart is racing at times.” Pulses are palpable +3 all extremities; capillary refill is instant. GI; Abdomen soft, no distended, and no tender with bowel sounds present in all four quadrants; skin is intact and warm. Current medications: Dilantin 400mg PO BID, Lexapro 20mg PO daily, Metoprolol 25

PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.

A 79-year-old female present with her daughter for ongoing fatigue also noted to have lost 5 pounds over past 6 months. No night sweats or fevers. Pertinent past medical history includes severe, generalized osteoarthritis, hypertension, type 2 diabetes mellitus and depression. She is taking the following medications: acetaminophen 650mg every eight hours, Lyrica 75 mg twice daily; alendronate 70 mg once weekly, valsartan 320 mg once daily, fluoxetine 40mg once daily and insulin glargine 20 units once daily. Your exam reveals slight pale conjunctivae, a 2/6 systolic ejection murmur and generalized arthritic joints in her extremities. A point of care test results in a hemoglobin of 10.2 g/dL. Complete blood cell count is done; results

Chest pain can be one of the most frightening medical conditions to both the patients and the health care practitioners. To most patients and healthcare providers, a chest pain can signify mostly an MI while a chest pain can be non-cardiac related issues. To better taking care of anyone who complains of a chest pain, the first intervention would be the MONA: morphine, oxygen, nitroglycerin and aspirin intervention. The next step is to have an electrocardiogram (ECG) done, and ABG, and a chest X-ray. In addition, the thyroid function level and the laboratory blood work would be ordered. According to Buttaro, et al. (2013), other diagnosis exams that can be ordered as part of the care plan for this patient can include complete blood counts (CBC), cardiac markers (creatine kinase [CK], CK-MB, and troponin levels), electrolytes (magnesium, potassium, and sodium), serum glucose, BUN, creatinine, urinalysis, and coagulation panel. Knowing the differential diagnoses for the patient with chest pain is

My patient was a 37 year old female; the patient throughout this reflection will be mentioned as KP. KP was admitted to 3 East for alcoholic cirrhosis of the liver. My patient has a long health history that includes asthma, severe malnutrition, muscle weakness, anemia, thrombocytopenia, and metabolic encephalopathy. She was currently NPO and received fluids and medicines through a Corpak. KP’s current health status slightly improving, but is still struggling to get better. Uncontrollable muscle contractions are inhibiting her ability to relax. Her change in mental status has affected her ability to be able to verbally communicate and follow commands.