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Caso 9 34y Male

Date: 09/19/21

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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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