Patient presents with a productive cough Generalised Malaise Sputum green in colour Occasional fevers Examination: Respiratory exam: Good Air entry bilaterally No Resp distress CREPITATIONS HEARD Reason for visit: Chest infection Management: Oral Antibioitics as prescribed Patient advised to: - Rest - Regular paracetamol +/- Ibuprofen - Drink plenty of fluids They have been advised to return here or present to ED should their symptoms worsen or if they have any concerns Keywords: +chestinfection, Penumonia
Patient complains of severe joint pain Joint/s affected: Patient states they have a history of gout and this feels like that On Examination: The patient is afebrile Joint affected feel hot and very sensitive to movement Clinical Impression : Gout Plan: 1. Anti-inflammatory medication prescribed (indomethicin, Colchicine or Prednisone) 2. Apply hot compresses or ice to the joint involved 3. Bed Rest Discussed the usefulness of Allopurinol. Not prescribed at this time but if continued attacks the patient will represent for treatment Discussed the "Rules of Moderation" and these notes have been printed and provided to the patient Rules of moderation Do: • restrict intake of food high in purines, especially organ meats (liver, brain, kidneys, sweetbread), shellfish and tinned fish (sardines, anchovies, herrings), game, pork • reduce your intake of alcohol, especially beer and red wine • reduce or cease intake of sugary, fizzy soft drinks and frui...
A prescription for Temazepam has been provided to be used as a short term treatment for insomnia. The patient was advised of the risk associated with this treatment: 1. Possible dependence 2. Tolerance ie. Continued use may cause the drug to lose its effectiveness 3. Morning sedation Encouraged to only use for a short term and try not to use more than 2 nights in a row I have also suggested other methods to assist with insomnia : - Guided meditation with apps / youtube - Don't drink coffee after 3pm - Reduce blue light exposure before bed or use apps to remove blue light on iphone/ipad - Increase physical output during the day but not immediately before bed Advised patient I would not prescribe this medication on an ongoing basis
Comments
Post a Comment