Caso 9 34y Male
Date: 09/19/21
Time: 23:00
Chief Complaint:
Testicular swelling, pain and discomfort.
Source: Patient
– History of Present Illness
HPI:
34 y/o male with past medical history Diabetes Mellitus, Hyperlipidemia, Hypertension, Hypothyroidism, morbid obesity came to emergency room due to edema and pain in testicles of 1 day of evolution. Refers start to feeling a weird sensation on testicles and some edema. Denies nausea vomiting or other constitutional symptoms.
– Allergies
Allergies/Adverse Reactions:
Allergies
Allergy/AdvReac Type Severity Reaction Status Date / Time
aspirin Allergy Mild Rash Verified 09/19/21 05:10
Home Medications
Medication Instructions Recorded Confirmed Type
Amlodipine Besylate [Amlodipine 10 mg PO DAILY 02/28/20 08/25/21 History
Besylate 10 mg Tablet]
Atorvastatin Calcium [Atorvastatin 20 mg PO BEDTIME 02/28/20 08/25/21 History
20 mg Tablet]
Levothyroxine Sodium 0.025 mg PO Q6AM 02/28/20 08/25/21 History
[Levothyroxine 0.025 mg Tablet]
Losartan Potassium [Losartan 50 mg PO DAILY 02/28/20 08/25/21 History
Potassium 50 mg Tablet]
Metformin HCl [Metformin 1,000Mg 500 mg PO Q12HR 02/28/20 08/25/21 History
Tablet]
hydroCHLOROthiazide 25 mg PO DAILY 02/28/20 08/25/21 History
[Hydrochlorothiazide 25Mg Tablet]
– Travel Risk – Coronavirus
Travel Risk: No
Contact Risk: No
Has patient experienced symptoms?: No
Past Medical History
Attestation statement: The following information was validated with the patient or family.
Source: Obtained From Patient
Accompained name: HERMANA
– Past Medical History
Medical History: Diabetes, Hyperlipidemia, Hypertension, Thyroid Disease (Hypothyroidism), Other (Morbid Obesity)
Hx Deep Vein Thrombosis: No
Blood Transfusion History: No
Surgical History Male: Other (I/D OF LEFT FOOT )
Psychiatric History: No Psych History
In the past week, have you been having thoughts about killing yourself?: No
– Family History
Family History: No Significant Family History
– Social History
Smoking Status: Never Smoker
Second Hand Exposure: No
Alcohol Use: No
Alcohol Intake: Never
Sustance Use: No
Subtance Use Type: Does Not Use
Lives: Family
ADL’s: Independent
Ambulation: Independent
Housing: House
Household Members: Family
Current Occupational Status: Unemployed
Current Occupational Exposures/Hazards: No
Review of Systems
– Constitutional
Constitutional: Report: No Symptoms Reported
– Eye
Eyes: Report: No symptoms reported
– Gastrointestinal / Abdominal
Gastrointestinal/Abdominal: Report: No Symptoms Reported
– Genitourinary
Genitourinary Male: Report: Testicular pain, Testicular swelling
– Musculoskeletal
Musculoskeletal: Report: No Symptoms Reported
– Skin
Skin: Report: No Symptoms Reported
– Neurological
Neurological: Report: No Symptoms Reported
– Psychiatric
Psychiatric: Report: No Symptoms Reported
– Endocrine
Endocrine: Report: No Symptoms Reported
– Hematology / Lymphatic
Hematologic/Lymphatic: Report: No Symptoms Reported
– Immunology / Allergies
Immunology/Allergies: Report: No Symptoms Reported
– All Other System
Report: Reviewed and Negative
Physical Examination
– Measurement
Vital Signs:
Last Vital Signs
Temp 36.3 C L 09/19/21 17:31
Pulse 89 09/19/21 17:31
Resp 17 09/19/21 17:31
BP 150/105 H 09/19/21 05:02
Pulse Ox 98 09/19/21 05:56
Height & Weight:
Height 5 ft 6 in
Weight 272.155 kg
– General Exam
General Limitations: Physical Limitations (Cant walk )
General Condition: Oriented x3, Awake, Alert, Active, No Aparent Distress
Physical Exam General Appearance: Comfortable, Cooperative, Mild Pain
Physical Exam General Nutrition: Morbidly Obese
– Head Exam
Head Exam: Normal Exam
– Eyes Exam
Physical Exam Eyes: Normal Appearance
– ENT Exam
Physical Exam ENT: Normal Exam
– Ear Exam
Physical Exam Ears: Normal Exam
– Nose Exam
Normal Exam
– Throat Exam
Normal Inspection
– Neck Exam
No Lymphadenopathy
– Thyroid Exam
Physical Exam Thyroid: Normal Inspection
– Cervical Lymph Node Exam
No Lymphadenopathy
– Chest Exam
Physical Exam Chest: Normal Inspection
– Respiratory Exam
Respiratory Exam: Normal Expansion, Normal Lung Sounds, Normal Respiratory Effort
– Cardiovascular Exam
Normal Rhythm, Normal Heart Sounds, Edema
– GI/Abdominal Exam
Normal Bowel Sounds, Flat, Soft
– Extremities Exam
Edema
– Lower Extremity Exam
Knee: Swelling
Ankle: Swelling
Lower Leg: Swelling
– GU Male Exam
Physical Exam Male Genitourinary: Swelling
Scrotal Exam: Swelling, Tenderness
Testicular Exam: Bilateral: Swelling
– Integumentary Exam
Other (scabiasis )
Distribution: Generalized
– Neurological Exam
Neurologic Exam: Normal Mood / Affect, Oriented x3, Alert, Normal Speech, Normal tone
Patient Oriented To: Person, Place, Time
– Psychiatric Exam
Normal Affect, Normal Mood, Cooperative
– All Other System
All Other System: Are not pertinent at the moment
Diagnosis Impression
(1) Anasarca
Code(s): R60.1 – Generalized edema Status: Acute
(2) Fluid overload
Code(s): E87.70 – Fluid overload, unspecified Status: Acute
Qualifiers:
Hypervolemia type: unspecified Qualified Code(s): E87.70 – Fluid overload, unspecified
(3) CHF (congestive heart failure)
Code(s): I50.9 – Heart failure, unspecified Status: Acute
(4) Diabetes mellitus with hyperglycemia
Code(s): E11.65 – Type 2 diabetes mellitus with hyperglycemia Status: Acute
Qualifiers:
Diabetes mellitus type: type 2 Diabetes mellitus long term insulin use: with long term use Qualified Code(s): E11.65 – Type 2 diabetes mellitus with hyperglycemia; Z79.4 – Long term (current) use of insulin
(5) Hypothyroidism
Code(s): E03.9 – Hypothyroidism, unspecified Status: Acute
Qualifiers:
Hypothyroidism type: unspecified Qualified Code(s): E03.9 – Hypothyroidism, unspecified
(6) Systolic congestive heart failure with reduced left ventricular function, NYHA class 4
Code(s): I50.20 – Unspecified systolic (congestive) heart failure Status: Acute
(7) Type 2 diabetes mellitus with morbid obesity
Code(s): E11.69 – Type 2 diabetes mellitus with other specified complication; E66.01 – Morbid (severe) obesity due to excess calories Status: Acute
(8) Type 2 diabetes mellitus with diabetic polyneuropathy
Code(s): E11.42 – Type 2 diabetes mellitus with diabetic polyneuropathy Status: Chronic
(9) Diabetes mellitus type 2, uncontrolled
Code(s): E11.65 – Type 2 diabetes mellitus with hyperglycemia Status: Acute
Qualifiers:
Glycemic state: with hyperglycemia Qualified Code(s): E11.65 – Type 2 diabetes mellitus with hyperglycemia
– Assessment and Plan
Assessment and Plan:
34 y/o male with past medical history Diabetes Mellitus, Hyperlipidemia, Hypertension, Hypothyroidism, morbid obesity came to emergency room due to edema and pain in testicles of 1 day of evolution. Refers start to feeling a weird sensation on testicles and some edema. Denies nausea vomiting or other constitutional symptoms. PE shows a calm, cooperative, oriented x3 male without any pain in testicle or any other complaints. Sinus tachycardia; rest of exploration within the normal limits.
Assessment: Fluid overload, systolic congestive heart failure, anasarca hypothyroidism, diabetes mellitus with morbid obesity, DM with polyneuropathy.
Plan: Furosemide, enoxaparin, carvedilol, insuline, levothyroxine, abx, valsartan, spironolactone, BMP, Diabetic diet, TSH, Hgb A1c monitor for acute changes, follow up.
– Labs
09/19/21 05:50
[Image 0]
09/19/21 05:50
[Image 1]
Labs Result:
Abnormal lab results
09/19/21 09/19/21 09/19/21 Range/Units
05:45 05:50 05:50
RBC 4.43 L (4.63-6.08) X10^6/uL
Hgb 10.8 L (13.7-17.5) g/dL
Hct 36.2 L (40.1-51.0) %
MCH 24.4 L (25.6-32.2) pg
MCHC 29.8 L (32.2-36.5) g/dL
RDW Std Deviation 46.6 H (35.1-46.3) fL
RDW Coeff of Var 15.6 H (11.6-14.4) %
Immature Gran % (Auto) 1.0 H (0.0-0.4) %
Lymph % (Auto) 11.7 L (19.3-53.1) %
Lymph # (Auto) 0.84 L (1.18-3.74) X10^3/uL
Mono # (Auto) 0.89 H (0.24-0.86) X10^3/uL
Immature Gran # (Auto) 0.07 H (0.00-0.03) X10^3/uL
BUN 45 H (9-20) mg/dL
BUN/Creatinine Ratio 43.2 H (7-25)
Glucose 337 H (74-106) mg/dL
Serum Osmolality 293.0 H (261-280) mOsm/Kg
Alkaline Phosphatase 355 H (38-126) U/L
NT-Pro-B Natriuret Pep (0.0-125.0) pg/mL
Albumin 2.8 L (3.5-5.0) g/dL
Globulin 4.2 H (2.4-3.5) g/dL
Albumin/Globulin Ratio 0.7 L (1.1-2.2)
Amylase Less than 30 L (30-110) U/L
Urine Protein 100 mg/dl A (Negative)
Urine Occult Blood Small A (Negative)
Urine Urobilinogen 2.0 eu/dl A (0.2 – 1.0)
Ur Leukocyte Esterase Moderate A (Negative)
09/19/21 Range/Units
05:50
RBC (4.63-6.08) X10^6/uL
Hgb (13.7-17.5) g/dL
Hct (40.1-51.0) %
MCH (25.6-32.2) pg
MCHC (32.2-36.5) g/dL
RDW Std Deviation (35.1-46.3) fL
RDW Coeff of Var (11.6-14.4) %
Immature Gran % (Auto) (0.0-0.4) %
Lymph % (Auto) (19.3-53.1) %
Lymph # (Auto) (1.18-3.74) X10^3/uL
Mono # (Auto) (0.24-0.86) X10^3/uL
Immature Gran # (Auto) (0.00-0.03) X10^3/uL
BUN (9-20) mg/dL
BUN/Creatinine Ratio (7-25)
Glucose (74-106) mg/dL
Serum Osmolality (261-280) mOsm/Kg
Alkaline Phosphatase (38-126) U/L
NT-Pro-B Natriuret Pep 9970.0 H (0.0-125.0) pg/mL
Albumin (3.5-5.0) g/dL
Globulin (2.4-3.5) g/dL
Albumin/Globulin Ratio (1.1-2.2)
Amylase (30-110) U/L
Urine Protein (Negative)
Urine Occult Blood (Negative)
Urine Urobilinogen (0.2 – 1.0)
Ur Leukocyte Esterase (Negative)
Admission Note
– Admission Information
Date of Admission: 09/19/21
Time of Admission: 14:01
Admission Diagnosis: Fluid overload, congestive heart failure, Diabetes mellitus type 2
Admission Note:
34 y/o male with past medical history Diabetes Mellitus, Hyperlipidemia, Hypertension, Hypothyroidism, morbid obesity came to emergency room due to edema and pain in testicles of 1 day of evolution. Refers start to feeling a weird sensation on testicles and some edema. Denies nausea vomiting or other constitutional symptoms. PE shows a calm, cooperative, oriented x3 male without any pain in testicle or any other complaints. Sinus tachycardia; rest of exploration within the normal limits.
Assessment: Fluid overload, systolic congestive heart failure, anasarca hypothyroidism, diabetes mellitus with morbid obesity, DM with polyneuropathy.
Plan: Furosemide, enoxaparin, carvedilol, insuline, levothyroxine, abx, valsartan, spironolactone, BMP, Diabetic diet, TSH, Hgb A1c monitor for acute changes, follow up.
Admission Day #: 1
Education Given on Admission: Diagnosis, Treatment, Medications, Procedure
Orientation to: Patient
– Vaccine
Hx Influenza Vaccination: No
Hx Pneumococcal Vaccination: No
DVT Prophylaxis (Adult)
– Assign risk score using criteria below
A. Risk Factors with value of 1 point each for PT > 41 years: Age 18-40 year (value-0), Bed confinement/immobilization > 24 hours, Obesity (>20% over IBW)
B. RFs with value of 2 points each: N/A
C. RFs with value of 3 points each: N/A
Total Risk Score = (A+B+C): 2
DVT Risk Level: Moderate Risk
Ambulation:
Early ambulation for all patients when possible, with assistence if necessary.
Patient is on therapeutic anticoagulation: Yes
Instrucciones ; van a realizar el plan de cuidado final discutido en clase el 25 de Sept. Los datos no encontrados hipotéticamente los completan. Trabajaran 3 problemas de enfermería, 2 lab. 2 radiografia, Y 3 medicamentos. Favor seguir las instrucciones del instrumento y la rúbrica. Siempre a las órdenes.




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