narrativenote.docx
Date: 02/13/2024
Name: J.W.
Age: 53
Sex: Male
Time: 13:00
Narrative Note:
Mr. Wales presented to the emergency department after falling approximately 10 feet from a ladder. Joe reports severe back pain rated at 10/10 on the pain scale and is observed to be diaphoretic and grimacing. Additionally, the patient’s pulse is noted to be above 100 beats per minute, indicative of tachycardia.
Upon further assessment, the patient reports bilateral leg weakness and limited flexion at the waist, The patient denies any allergies and reports having taken 2 tablets of Motrin 200 mg one hour after the fall, without experiencing any relief. Joe Wales reports quit smoking one year ago. Joe spontaneously drinks 3 to 4 beers on weekends with her wife at home.
Vital signs at admission were as follows: BP 138/80 mm Hg, HR 112 beats per minute, Resp 24 breaths per minute, and oxygen saturation 98% on room air.
Physical examination reveals significant findings consistent with severe back pain. The patient requires assistance to sit on the examination table and clenches the jaw with position changes. Lower back support with hands is observed, and there is significant tenderness of the lumbar spine. The patient is unable to perform hip flexion/extension or spinal range of motion due to pain.
Abdominal examination reveals bowel sounds in all four quadrants, with a soft abdomen. The patient is voiding spontaneously, and urine appears clear with no sedimentation. Laboratory blood results are within normal range limits.
Imaging studies conducted in the emergency department show a herniated lumbar disc, which corresponds with the patient’s clinical presentation and symptoms.
Joe will be monitored closely in case of any changes.
Nurse: Yanai Gonzalez
CaseStudyforAssessmentDocumentation–DJ2.pdf
CASE STUDY FOR ASSESSMENT AND DOCUMENTATION
Follow the instructions given in class.
Case scenario:
Daniel Johnson, a 52-year-old male, presents with fatigue and cough for the past 6 months, and chest
pain for the past 2 days.
Vital Signs: T- 38.2 C (100.8 F); BP 142/92 mmHg; Pulse 91/bpm; RR 26/BPM; Pulse Oximetry 92% on
Room Air.
Health History Interview data collected:
1. Cough worsening during the last 6 months; Dry and Hacking 2. Sputum, small quantity, blood tinged 3. States night sweats 4. Some days present low grade fever 5. Chest pain: on the right side, sharp, worse when he breaths deeply, started a few days ago, 4/10, no radiation. 6. He gets better and improves with cough suppressants and OTC APAP 7. Over the last 4 months, doesn’t feel hungry 8. 20 lb weight loss until today (the day of the visit) for the past 4 months 9. NKDA 10. No similar illness in the past 11. No hospitalizations or surgery; No blood transfusion; No prescription medications 12. OTC APAP 13. History of previous recurrent pneumonia (2 months ago); treated with Augmentin 800 mg 14. Skip follow-up visits after Pneumonia event 15. No significant family history 16. Travel to Mexico 3 weeks ago. Not been around anyone sick 17. Recently released from prison (7 months ago); cellmate with serious cough 18. Heroin use; no alcohol; quit smoking last year; previously 35 pack/year 19. Unsure of HIV status 20. History of sex with men
Physical Examination data
1. Multiple tattoos in both arms, chest and back
2. Tactile fremitus bilaterally
3. Tenderness on right side of anterior chest
4. Bilateral basilar crackles
5. Clubbing
6. lips cyanosis
7. SOB with activity
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