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An 87-year-old African American widowed male was admitted to the hospital with recurrent pneumothorax, lung cancer, and chest pain. He has a history of hernia repair, knee replacement, and deep vein thrombosis. Lab tests showed high glucose, BUN, creatinine, and coagulation levels. He is taking multiple medications to treat hypertension, arrhythmia, gout, COPD, and infections. His care plan focuses on proper hydration, weight loss, regulating blood pressure through diet, and learning healthy cooking.
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An 87-year-old African American widowed male was admitted to the hospital with recurrent pneumothorax, lung cancer, and chest pain. He has a history of hernia repair, knee replacement, and deep vein thrombosis. Lab tests showed high glucose, BUN, creatinine, and coagulation levels. He is taking multiple medications to treat hypertension, arrhythmia, gout, COPD, and infections. His care plan focuses on proper hydration, weight loss, regulating blood pressure through diet, and learning healthy cooking.
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SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docx
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
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Eyes
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Case presentation on MYOCARDIAL INFARCTION
A blockage of blood flow to the heart muscle. A heart attack is a medical emergency.A heart attack usually occurs when a blood clot blocks blood flow to the heart.Without blood,tissues loses oxygen and dies
Pharmacology Review Chapter 29-38
The document discusses the sympathetic nervous system response to stress and the effects of norepinephrine. It describes the actions of alpha-1, alpha-2, beta-1, and beta-2 receptors on various organs. It then discusses the parasympathetic nervous system response and effects of acetylcholine. Various case studies are presented on adrenergic drugs, cholinergic drugs, thyroid hormones, glucocorticoids, antihyperglycemic agents, and monitoring of diabetes.
Asthma case study by abhishek pandey
A 48-year-old female patient presented with breathlessness, chest tightness, and cough with expectoration. Physical examination revealed dyspnea, tachycardia, and abnormal lab results. Spirometry showed 62% of predicted FEV1. She was diagnosed with acute exacerbation of asthma. Her treatment plan included bronchodilators, antibiotics, leukotriene inhibitors, and vitamin supplements. A clinical pharmacist counseled the patient on medication use, disease management, and lifestyle modifications like exercise and diet.
Emergency Nursing of the Trauma Patient
1) ED nurses should have a sound knowledge of trauma care as EDs are seeing more trauma presentations who are spending more time in the ED.
2) The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is key for assessing and treating trauma patients in the ED to prevent death, which can occur within hours from hemorrhagic shock or weeks from sepsis.
3) A full trauma assessment from head to toe is important to identify injuries and provide interventions like splinting fractures, inserting chest tubes, or preparing for emergency surgery. Serial monitoring of vital signs and investigations helps guide treatment effectiveness.
soap Duodenal Ulcer.docx
This soap note is for a 68-year-old male presenting with headaches and high blood pressure readings over the past two weeks. On examination, his blood pressure was elevated at 159/92 mmHg. The main diagnosis is essential (primary) hypertension. Differential diagnoses include renal artery stenosis, chronic kidney disease, and hyperthyroidism. The plan is to order labs and diagnostic tests, start antihypertensive medications, implement non-pharmacologic treatments like diet and exercise changes, and follow-up in one week to manage his blood pressure.
Clinical Lecture Demonstration - Stroke, Thyrotoxic Cardiomyopathy and Paroxy...
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Clinical Lecture Demonstration - Stroke and AF
Summary
74 years old known patient with hyperthyroidism, DM, HTN, DL, Paroxysmal AF & Thyrotoxic cardiomyopathy Presenting with right sided arm, leg weakness for two hours duration. No loss of consciousness preceding headaches fits or double vision. patient is a passive smoker. No other risk factors present. HTN is well controlled. On Examination Right sided UMN type Facial nerve palsy with dysarthria and Power, Tone, Reflexes are diminished on Right Upper and Lower limbs
by,
Pamudith Karunaratne
Heshani Karunanayake
Monali KalupahanaCHRONIC LIVER DISEASE WITH PORTAL HYPERTENSION , ESOPHAGEAL VARICES, UPPER GI...
This document describes the case of a 30-year old patient presenting with chronic liver disease, portal hypertension, esophageal varices, and upper GI bleeding. Over the course of 9 days in the hospital, the patient received various medications and blood transfusions. Vital signs were monitored daily and showed gradual improvement. The patient was educated on lifestyle modifications and disease management upon discharge.
Angina, cardiovascular disease, Heart, Health
This case presentation summarizes a 60-year-old female patient admitted with unstable angina who presented with chest pain, dizziness, and vomiting. Objective examination found T-wave inversion on ECG. She was diagnosed with unstable angina and treated with medications like metoprolol, clopidogrel, aspirin, and atorvastatin. Her symptoms improved over her hospital stay and she was discharged on a regimen of medications to be continued, with monitoring of side effects and follow up.
dolor
Chest pain is a common reason for emergency room visits. According to the document, chest pain accounts for over 2 million ER visits per year in the US. It can be difficult to accurately diagnose the underlying cause of chest pain. The document discusses several cases of patients presenting with chest pain and the process of gathering a history, performing a physical exam, ordering tests, and arriving at a diagnosis for each case, which include acute myocardial infarction, pericarditis, pulmonary embolism, and aortic dissection.
世界新建築
Chest pain is a common reason for emergency room visits. According to the document, chest pain accounts for over 2 million ER visits per year in the US. It can be difficult to accurately diagnose the underlying cause of chest pain. The document discusses several cases of patients presenting with chest pain and the process of gathering a history, performing a physical exam, ordering tests, and arriving at a diagnosis for each case, which include acute myocardial infarction, pericarditis, pulmonary embolism, and aortic dissection.
dolor
Chest pain is a common reason for emergency room visits. According to the document, chest pain accounts for over 2 million ER visits per year in the US. It can be difficult to accurately diagnose the underlying cause of chest pain. The document discusses several cases of patients presenting with chest pain and provides diagnostics and treatments for common conditions that cause chest pain, such as myocardial infarction, pericarditis, pulmonary embolism, aortic dissection, costochondritis, and gastroesophageal reflux disease. A thorough patient history and physical exam, along with diagnostic tests, are important for correctly identifying the source of a patient's chest pain.
dolor dolor
Chest pain is a common reason for emergency room visits. According to the document, chest pain accounts for over 2 million ER visits per year in the US. It can be difficult to accurately diagnose the underlying cause of chest pain. The document discusses several cases of patients presenting with chest pain and the process of gathering a history, performing a physical exam, ordering tests, and considering potential diagnoses for each case, including acute myocardial infarction, pericarditis, pulmonary embolism, and aortic dissection.
dolor again
Chest pain is a common reason for emergency room visits. According to the document, chest pain accounts for over 2 million ER visits per year in the US. It can be difficult to accurately diagnose the underlying cause of chest pain. The document discusses several cases of patients presenting with chest pain and the process of gathering a history, performing a physical exam, ordering tests, and arriving at a diagnosis for each case, which include acute myocardial infarction, pericarditis, pulmonary embolism, and aortic dissection.
Chest pain is a common reason for emergency room visits. According to the document, chest pain accounts for over 2 million ER visits per year in the US. It can be difficult to determine the underlying cause of chest pain based on symptoms alone. A thorough history and physical exam is important to help differentiate between potentially life-threatening causes like heart attacks versus more benign causes like costochondritis or gastroesophageal reflux. Proper diagnosis and treatment is key to improving outcomes for patients experiencing chest pain.
dolor 2
Chest pain is a common reason for emergency room visits. According to the document, chest pain accounts for over 2 million ER visits per year in the US. It can be difficult to determine the underlying cause of chest pain based on symptoms alone. A thorough history and physical exam is important to help differentiate between potentially life-threatening causes like heart attacks versus more benign causes like costochondritis or gastroesophageal reflux disease. Proper diagnosis and treatment is crucial, as patients who experience a heart attack but are mistakenly discharged have high short-term mortality rates.
SLE MNM
The patient, a 16-year-old female, presented with a history of systemic lupus erythematosus diagnosed in 2021 and was admitted for abdominal pain, vomiting, and loss of appetite. Her condition deteriorated and she developed sepsis. Laboratory findings showed anemia, leukocytosis, renal impairment, and markers consistent with active lupus. Despite aggressive management including intubation, pressors, and pulsed steroids, her condition continued to decline and she suffered cardiac arrest. She could not be resuscitated and was declared dead. The final diagnosis was septic shock, enterocolitis from mesenteric vasculitis, and active systemic lupus erythematosus involving hemolytic anemia
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Case4ppt
- 1. Case #4 Sarah Tefft December 11, 2008
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