Cythes Case Summary

Normocephalic atraumatic. Pupils equally round and reactive to light, extraocular motions intact. Oral cavity shows oropharynx clear but slightly dried mucosal membranes. TM (tympanic membranes) clear. Neck, supple. There is no thyromegaly, no JVD. No cervical supraclavicular, axillary, or inguinal lymphadenopathy.

HISTORY AND PHYSICAL EXAMINATION_______________________ Patient Name: Chapman Robert Kinsey Patient ID: 110589 Room No.: 322-B Date of Admission: 23 February ---Admitting Physician: Martha C. Eaton, MD, Geriatrics Chief Complaint: Admitted from Dr. Max Hirsch’s office due to deep ulcer on left toe. Admitting Diagnoses 1. Severe peripheral vascular disease, status post deep ulcer on left toe. Rule out thrombolysis. The patient was admitted to a regular floor. Condition is serious. 2. ALLERGY TO PENICILLIN, which puts patient into anaphylactic shock. 3. Continue with home medications. DETAILS OF PRESENT ILLNESS: Mr. Kinsey is an 87-year-old white gentleman with history of (1) Chronic atrial fibrillation, on Coumadin. (2) Chronic deafness,

My patient is a patient that is leaving the E.R. after being diagnosed with the shingles virus. The patient came into the E.R. with a rash on the right side of the trunk. The rash presented as clear blisters and was painful to the touch. The physician diagnosed the patient with

On 4 June 2018 at around 2pm, I visited Mr. Mueller at his home located on Fort Drum, NY. Mr. Mueller is awake, alert, and oriented to person and location. When evaluating his hearing, Mr. Mueller is able to repeat whispered words appropriately. Evaluation of breathing pattern while watching his nostrils reveals unlabored breathing with no nasal flaring. Lymph nodes post-auricular, submandibular, and supraclavicular are not swollen and Mr. Mueller does not report pain during palpation of lymph nodes. Assessment of eyes reveals bilateral quick reacting pupils to light. Extraocular movement test is normal; Mr. Mueller is able to follow the pen with his gaze. Lung sounds are clear bilateral, breathing pattern

BB’s skin presents as pink, warm and dry. No obvious signs or symptoms of abnormal bruising or lesions present however, the patient states that the skin has of late has

L.H. report no concurrent or severe headaches; There was no head trauma, syncope or vertigo. Patient wears corrective lens with no difficulty of vision or diplopia; absent of inflammation, discharge or lesion. Last eye exam was in September of 2016 with no history of glaucoma, cataracts. L.H. denies having any frequent colds, sinusitis, epistaxis and trauma. Patient reports having obstruction stating, “it happens when I am lying down” with an occasional postnasal drip.

We did talk about treatment options. I like him to start using warm compresses on his eyes. We talked about keeping his hands clean and to wash frequently, as this is this is very contagious. He and mom will monitor those symptoms, but if there is no improvement will start using the Polytrim prescription that was given using one drop four times daily for five to seven days. They do know if the symptoms are not improving here in the next few days, they are follow up or return to the office for evaluation. I do have a strep culture pending at this time. I suspect that will be negative. If the cold symptoms are not improving towards the end of the week, consideration for adding antibiotic can be done. He does have a history of asthma, though currently, his lungs are great in the office. Mom is going to start using his albuterol on a scheduled basis for the next couple of days and then p.r.n. from there. We did talk about adding steroids, including oral steroids versus an inhaled corticosteroid. Mom would like to hold off on that for now as he previously had symptoms, especially with oral steroids affecting his mood. I do not think this is unreasonable based on how he is sounds in the office. However, she is aware that if the symptoms do acutely worsen, they will seek care, and if there is no improvement will contact me so we can add those in.

Crackles are noted in the lungs throughout. Heart is regular rate and rhythm with a rate in the 90s. Patient is on telemetry. Bowel sounds are active x4. Denies abdominal tenderness. Skin is dry and intact.

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.

Auricle, tragus, lobule all present and symmetrical bilaterally. Auricle aligns with canthus of each eye, and has 10-degree angle of the vertical position bilaterally. Earlobes are free. Skin smooth, no lesions, lumps, or nodules. No discharge present. Color consistent with face bilaterally. Auricle, tragus, and mastoid process are nontender bilaterally. Scant amount of yellow cerumen in external auditory canal bilaterally with no edema, drainage, redness, or swelling noted. Right tympanic membrane is pearly grey, shiny, translucent, no bulging noted. Cone of light present at 5 o’clock. Umbo and handle of malleus visible. Left tympanic member is pearly grey, shiny, translucent, no bulging noted. Cone of light present at 7 o’clock with umbo

Head and Neck: Patient skull is of normocephalic, atraumatic and without masses. The patient 's facial expression and facial contours are normal. The parotid glands are normal. The sinuses are non-tender. Palpation of the temporal and masseter muscles reveals normal strength of muscle contraction. There is symmetry of the nasolabial folds. There is no facial droop noted. Trachea midline. Thyroid is smooth, no goiter or

had crusty scabs. One day the redness worked its way down to his left cheek and it cracked open,

Mr. Vallee is a 52-year-old male here today complaining of a lump on the left side of the back of his head.

Patient complains of frequent diarrhea alternating with constipation, which has been going on for years due to Crohn’s disease. He also reports an ingrown toe nail and it is has been hurting for several weeks.

Over the next month, which puts us in December, Johnny had developed two more smaller lumps and a very large lump on his neck. He also developed two large lumps on the top of his head. He was running a fever again. He had been running fevers on and