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Medical Case Presentation

Transcript: Medical Case Presentation Timeline A 5-Day Timeline of Events Timeline 5 Timeline 2. 4. 2. 4. 4 2. 4. Future Considerations Complications Encountered Revised Diagnosis Looking forward, this case highlights the need for improved protocols in patient monitoring and a more integrated approach to multidisciplinary care. Future practices should focus on leveraging technology for better tracking of patient conditions and enhancing communication among medical teams. Further Testing The patient exhibited signs of respiratory distress and electrolyte imbalance, indicating potential complications from treatment. These issues necessitated immediate reassessment of the patient’s condition to prevent further deterioration. The results from Day 2 testing indicated an evolving clinical picture, leading to a revised diagnosis of a potential systemic infection. This shift underscored the importance of adaptability in medical diagnoses and treatment protocols when patient conditions change. In response to the patient’s declining status, further diagnostic tests were conducted, including blood cultures and imaging studies. These investigations aimed to identify underlying causes of the patient's deterioration and to tailor an effective treatment strategy. Demographics Day 4 Events: Complications and Responses 3 Key Learnings Conclusion Patient Profile Critical insights from this case emphasize the importance of timely interventions, comprehensive assessments, and collaboration among healthcare professionals. The evolving nature of patient conditions necessitates continuous monitoring and adaptability in treatment approaches. This section encapsulates the timeline of events, highlighting the critical insights gained throughout the medical case presentation over five days. The patient is a 45-year-old male, presenting with no known allergies. He lives alone and works as an accountant, leading a sedentary lifestyle. This demographic information provides insights into potential health risks and lifestyle-related conditions. Adjustments in Treatment Understanding the patient profile is essential for effective diagnosis and treatment. This section summarizes crucial demographic information, medical history, and current medications for a holistic view of the patient's health. Day 2 Events On Day 4, the patient experienced unexpected complications, altering the treatment trajectory. Prompt adjustments were necessary to effectively address new clinical challenges and ensure patient safety. In response to the complications, the treatment plan was modified to include supplemental oxygen and intravenous fluids for rehydration. This prompted close monitoring to evaluate effectiveness and mitigate further risks. Current Medications Changes in Patient Condition Medical History Consultations with Specialists Summary of Timeline On Day 2 of the case trajectory, significant changes in the patient's condition prompted immediate reevaluation. This set the stage for a series of critical tests and a necessary revision of the initial diagnosis, illustrating the evolving nature of medical assessments. Currently, the patient is on Lisinopril for hypertension. Additionally, he takes a multivitamin daily but reports no use of over-the-counter medications or supplements, which is critical for medication reconciliation. By Day 2, the patient exhibited noticeable alterations in vital signs, including elevated heart rate and fluctuating blood pressure. Symptoms such as increased discomfort and altered consciousness levels were reported, necessitating reassessment of the treatment plan. The patient has a medical history of hypertension diagnosed 5 years ago, managed with lifestyle changes. There is no significant surgical history or family history of chronic diseases, which influences the treatment options available. With the emergence of complications, consultations with pulmonology and nephrology specialists were initiated. Their insights guided the medical team in refining the treatment strategy and ensuring comprehensive care. The timeline of this case illustrates a series of pivotal events leading from initial symptoms to final assessments over five days. Key decisions and interventions shaped both the patient’s experience and outcomes, reinforcing the value of structured medical timelines in patient care. 2 3. 1. 1 Overview of Medical Case Discharge Planning Outcome of Treatment The medical case involves a patient who presented with multiple symptoms requiring a systematic analysis. Over five days, various diagnostic tests, treatments, and responses will be chronologically detailed to illustrate the clinical journey and decision-making process. 3. 1. Discharge planning involved a multidisciplinary team assessing the patient's needs for home care, follow-up appointments, and medication instructions. Effective communication and coordination ensured the patient understood their post-discharge care, minimizing the risk of complications. The treatment plan

Medical Hypnosis Case Presentation

Transcript: Medical Hypnosis Interview AD is healthy 23 year old with an unremarkable medical history. She is a student at SCNM in her 3rd year. She likes school and is very excited about this medicine and being part of this profession. She has noticed becoming more overwhelmed and stressed since starting to see patients at the clinic 12 weeks ago. She wants learn everything so she can be the best doctor possible to help her patients. She admits she is hard on herself. ROS: Occassionally she has GI upset which she believes comes from a gluten sensitivity as she notices it after eating foods with gluten. She feels bloated, has cramping and notices dry patches of skin with pruritis "cold application makes itching feel better" 30 min hypnotherapy session given using progressive muscle relaxation followed by imagery of a control box for pruritis, cool stream and her skin breathing Patient reported feeling much less itchy in the following week and 2 weeks later reported erythema and flaking is resolved! "feels as if skin is tingling and suffocated Treatment & Results PMH Emily Poccia HPI: AD is a 23 y/o pleasant and positive female PTC with a CC of pruritis and dermatitis like skin rash around her neck and forearms. The itching and inflammation stated 3 weeks ago and is extremely itchy. The pruritis seems to be “non-stop” and scratching temporarily relieves the sensation but leaves the skin drier and flaky. Some skin flakes off with scratching. The pruitits is worse at night especially when she is trying to fall asleep and this prevents her from doing so. She is only getting a few hours of uninterrupted sleep at night. It is a 6/10 for discomfort during the day and 9/10 at night. She also states that she feels more stressed and over whelmed recently especially since starting to see patients of her own in the clinic. Cold application seems to help. She is in distress due to discomfort and lack of sleep, otherwise a healthy and high spirited young women. Physical Exam Mental Status Exam Imagines self jumping into a cool stream Skin: Erythemetous base that is confluent and wraps around her neck with generalized declamation. Papulosquamous and eczematoid. Also seen on forearms. Ideal situation would be to decrease itching, flaking and redness. Feels self conscious about how it looks. The more I think about it the more it itches and the more I get stress out about it affecting my sleep. AD is appropriate weight and height for age and gender. She is a pleasant looking female with clean casual attire. The patient has good eye contact was pleasant and willing to try anything to help her discomfort. Her speech is within normal limits. She has a happy cheerful disposition with good judgement and insight and is just distressed about her skin and it's impact on her sleep. She does seem to scratch often especially when talking about it. CC: Pruritis and Dermatitis

Medical Case Presentation

Transcript: Boulanger David medicine student Medical case presentation Identity Identity Name: Johnson Forname: William DOB: 24th September 1979 Occupation: Teacher (school director) Social status: Married Child: 2 (girl: 12 boy: 8) Live in: Grenoble (France) Symptom(s) Symptom(s) - Dizziness - Headache - Muscle aches - Insomnia - Nausea and vomiting - Irritability - Loss of appetite - Swelling of the hands, feet, and face - Rapid heartbeat - shortness of breath with physical exertion - Coughing - Chest congestion - Pale complexion and skin discoloration - Inability to walk or lack of balance - Social withdrawal Family history (FH) Family history (FH) TIME FATHER: myocardial infarction (67) MOTHER: Diabetes (32) Siblings: NAD Past medical history Past medical history TIME appendectomy (14) tonsillectomy (15) withdrawal of wisdom teeth (18) Broken leg (23) Social history (SH) Social history (SH) TIME Walking Trekking Climbing Swimming Skiing Examination (O/E) Examination (O/E) examination (O/E) examination (O/E) Weight: 70 Size: 1.75 Weight: 70 Size: 1.75 BP: 140/80 BP: 140/80 P: 180 P: 180 Respiratory frequency 20 / Min Respiratory frequency 20 / Min P02: 92% P02: 92% T: 37.5°C T: 37.5°C DIAGNOSIS DIAGNOSIS Acute Mountain Sickness (AMS) ? Acute Mountain Sickness (AMS) Treatment Treatment Medications : acetazolamide, to correct breathing problems blood pressure medicine lung inhalers dexamethasone, to decrease brain swelling aspirin, for headache relief Other treatments Lower altitude Lower altitude At rest At rest Water Water

Medical Case Study Presentation

Transcript: Physical Examination Overview of the Case Study Physical examination is a key component of the diagnostic process, providing valuable insights into the patient's overall health status and guiding further investigations. The case study revolves around a 45-year-old female patient with a history of hypertension and diabetes, presenting with symptoms of fatigue, cough, and weight loss. Understanding her medical background and initial symptoms is imperative for diagnosis and treatment planning. Diagnostic Process and Findings Initial Symptoms Presentation Patient Background The patient presented with symptoms of severe fatigue, persistent cough, and gradual weight loss, indicating potential underlying health concerns. The patient is a 45-year-old female with a history of hypertension and diabetes, providing vital context for her current health condition. The diagnostic process involves a thorough evaluation of the patient's condition through physical examination, laboratory tests, imaging studies, and differential diagnosis to determine the underlying cause of symptoms. Laboratory Tests Medical History Laboratory tests, including blood work and urine analysis, help in assessing the patient's biochemical profile, inflammation markers, and organ function, aiding in the diagnosis process. The patient has a history of respiratory infections and a family background of cardiovascular diseases, influencing her current health status. Imaging Studies Differential Diagnosis Imaging studies like X-rays, CT scans, and MRIs provide visual evidence of internal structures, helping to identify injuries, abnormalities, and diseases accurately. Differential diagnosis involves considering various potential conditions based on symptoms and test results to arrive at an accurate diagnosis and treatment plan for the patient. Long-term Health Monitoring Long-term monitoring is vital to track patient progress, identify potential issues, and adjust treatment plans for sustained health improvement. Collaborative Care Approach Ensuring Patient Compliance Collaboration among healthcare professionals, patients, and caregivers ensures coordinated care delivery and better treatment outcomes. Patient education and engagement are essential to ensure adherence to the treatment plan and promote positive health outcomes. Recommendations for Continued Care Effective Treatment Plans in Action Based on evaluation results, healthcare providers make further treatment recommendations for optimal patient health and well-being. Real-life cases demonstrate the effectiveness of tailored treatment plans in improving patient health outcomes and quality of life. Treatment Plan and Outcome The treatment plan is a critical aspect of patient care, tailored to address specific medical needs and conditions. Medical Case Study Presentation Evaluating Treatment Outcomes Enhancing Patient Empowerment Outcome evaluation involves assessing treatment effectiveness, measuring symptom improvements, and determining the patient's overall health status. Empowering patients through education, involvement in decision-making, and self-care practices positively impacts treatment adherence and health outcomes. Future Trends in Patient-Centered Care Importance of Follow-up Care Analyzing a Complex Patient Scenario Developing a Comprehensive Treatment Plan The future of healthcare includes advancements in patient-centered care, utilizing technology, data analytics, and personalized medicine for improved treatment outcomes. Follow-up care is crucial to monitor patient progress, adjust treatment strategies, and prevent complications or relapses. A comprehensive treatment plan involves a personalized approach to address the patient's medical needs, incorporating medications, therapies, and lifestyle modifications.

Medical Case Presentation

Transcript: O God, that men should put an enemy in their mouths to steal away their brains! That we should with joy, pleasance, revel, and applause transform ourselves into beasts! William Shakespeare (1564-1616) British poet and playwright. 48 year old Caucasian female "My stomach is really hurting" HPI 48 y/o lady with a PMH of alcoholic liver cirrhosis, and esophageal varices "My stomach really hurts" She's been having abdominal pain for the past 6 days. Describes the pain as dull (constant and diffuse) 8/10 in severity starting from the epigastrium moving to the lower part of the belly. She feels relief when she lies down and worse sitting up. She also mentions that she noticed gradual distention of her belly for the past three weeks. She denies any nausea, vomiting, weight loss, or fever but notices some swelling in her left leg. In addition, she has recently been experiening some shortness of breath. She has dyspnea on exertion but denies orthopnea and paroxysmal nocturnal dyspnea. Of note, she mentions that she had similar belly pain 2 weeks ago which was associated with episodes of bloody vomiting. She went to Eastern Shore Hospital, admitted for upper GI bleed, underwent a panel of tests that included an endoscopy, ultrasound, and ascitic tapping and diagnosed with liver dx. She also mentions that she felt a lot better after that and hoped to get tapping done at SAH. Past Medical History Alcoholic liver cirrhosis Grade one esophageal varices Anemia Hx of thrombocytopenia Anxiety disorder GERD Cholecystitis Alcohol abuse Past Surgical History Rhinoplasty Allergies Acetaminophen (rash) Oxycodone (nausea) Medications Propanolol 10 mg po BID Pantoprazole 40 mg po BID Lactulose 15 mg po Qday Spironolactone 25 mg po Qday Sertraline 100 mg po Qday Clonazepam 1 mg po BID Review of Systems General: Muscle weakness, fatigue, and chills HEENT: No headaches, vision change, hearing changes, sinus troubles, bleeding gums, swollen glands Cardiac: No chest pain, palpitations Resp: Cough (non productive) and wheezing Breasts: No lumps, pain, nipple discharge GI: per HPI GU: No trouble urinating, no pain on urination, no hematuria, LMP was three years ago Extremities: per HPI Skin: No rashes, lesions, or color changes Endocrine: No heat or cold intolerance, excessive thirst or hunger Neuro: No seizures, numbness, or tingling Hematologic: No easy bruising or past transfusions Physical Exam 99.0 T 76 P 18 RR 115/60 BP 97% on 2L nasal cannula Weight: 70.307 kg General: Middle aged lady, in obvious pain but no acute respiratory distress, alert and oriented to person, place, and time. HEENT: Scalp normal, pupils equally round and reactive to light and accomodation. Fundoscopic exam reveals normal vessels, tympanic membranes are normal, oral pharynx is normal, neck is supple, no abnormal adenopathy in cervical or supraclavicular areas, thyroid is normal without any masses. Cardio: No murmurs/rubs, heart sounds S1 and S2 are present. Resp: Decreased air entry over the rt lower lung field, some expiratory wheezing bilaterally. GI: The abdomen is distended and bulging at the flanks but not tense, diffuse tenderness to palpation exquisitely over the epigastrium, Murphy's sign not present, bowel sounds are present, positive for shifting dullness, liver palpable 2 fingers below the subcostal margin, unable to appreciate exact size of liver or any splenomegaly MS: No cyanosis, clubbing, or edema noted. Peripheal pulses in the dorsalis pedis, and radial arms are normal. Skin: Multiple spider angiomas over subclavicular region, face and shoulders Neuro: Alert, oriented x3, CN II-XII intact, power 5/5 all extremities. March 10: Hypoxic requiring 100%FIO2 and PEEP of 12. March 11: Breathing improving requiring PEEP of 5 and FiO2 of 40%. Renal function improving with the CVVHD March 12: Breathing treatment the same, worsening encephalopathy, sedated but arousable, does not follow commands this am, eye opening present. CT of abdmn showed mild ascites, possible ascending colitis. Displaying multiorgan failure. March 13: Family decides to change code to DNI/DNR and request pt to be extubated with pastoral services present. March 14: Pt displays agonal breathing, no longer arousable. On morphine drip for pain. March 15: Worsening agonal breathing, no longer arousable. On morphine drip for pain. March 16: Pt passes away at 6:21pm. SBP Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection in the peritoneum and severe consequence of ascites. Patients with cirrhosis who are in a decompensated state are at the highest risk of developing spontaneous bacterial peritonitis. Patients at greatest risk for spontaneous bacterial peritonitis have decreased hepatic synthetic function with associated low total protein level or prolonged prothrombin time (PT). The diagnosis is established by a positive ascitic fluid bacterial culture and an elevated ascitic fluid PMN count >250 cells/mm3 SBP Fever and chills occur in as many as 80% of patients.

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