Patient One- Chapter 6 Subjective- Patient presents stating that is having severe back pain for the past five days. Patient states that she is not on any medications at the current time. Patient was told in the past that she has sickle cell anemia. Patient states that she has been have headaches regularly. Patient also states that she has not been eating much, but is able to keep food down and is able to go to the bathroom without problems. Objective- A 22-year-old African American female presents at the hospital and vitals are 99 degrees orally, pulse 38, respirations 22, blood pressure 140/60. Assessment- Skin- within Normal Limits, Head, eyes, ears, nose and throat- Within Normal Limits, Patient is alert. Abdomen pain over the lower spine. Blood work (BMP) is White Blood cells (WBC) 4300, Hemoglobin 13.1g/dl, Hematocrit 39.9, Platelets 162,000, segs 69.9, lymphs 27, monos 3.4. Plan- Physician tells patient that she will be admitted to the hospital with a diagnosis of Sickle Cell Crisis and that an IV will be started that will contain medication for pain and give the patient necessary fluids that are needed in the overnight period that patient will be admitted and the physician will see patient in the morning. Patient 2 Chapter 7 Subjective- Patient presents at the ER stating that "I am having pain in bottom area." Patient stated that he saw a pimple on his buttocks and then it started to hurt. Patient stated that the ER opened and drained the pimple of fluid and they (ER) did some blood work and have yet to hear any results of this work. Patient has no further complaints.
Objective- Patient is a 26-year-old male born on 2/2/1984. Vital signs are Temperature-98 degrees, Pulse 90, Respirations 15, Blood pressure 115/80, Height 62 inches, Weight 215 lbs., Patient is Insulin dependent and blood glucose is in the range of 200 and patient has a history of