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Case Study: Mr. Brown Dx: Partial thickness burn face, (right) hand and (right) thigh, date of birth October 1st, 1975.
Secondary Dx (diagnosis):
Schizophrenia, HTN (hypertension)
PMH (past medical history):
drug abuse (rehabX3)
Allergies: Strawberries, dust, elastplast tape, Hydromorphone
Medication: Norvasc 10mg, PO (by mouth) OD (Oculus dexter), Zyprexa 15 mg po od
History of present illness: Mr. Brown is a 46 year old malewho sustained a full thickness thermal burn while at work. Mr. Brown works in a plastic factory in Toronto, Ontario. Mr. Brown reported that he attempted to remove some plastic that was stuck in the machine when the plastic "flew out" once the machine was fixed. The hot plastic became stuck to Mr. Brown's face, hands, and thigh. Mr. Brown reported that he left work and went home. Mr. Brown reported that his colleagues advised him to go to the ED (emergency department) however he declined. Mr. Brown is a recent immigrant to Canada and reported that he "didnot want to cause any problems".
Mr. Brown noticed that there was no improvement to his injury after 5 days and decided to go to his family doctor for assessment. After being assessed by his family doctor, Mr. Brown was advised to go to the ED immediately. Mr. Brown went to Sunnybrook Health Science Centerwhere he was treated with IV abx (inravenous antibiotics) and was seen by Plastic surgeon. The patient will also require reconstruction surgery as some of the plastic is still embedded in his hand and thigh. Mr. Brown reported that his supervisor refuses to contact WSIB (workplace Safety and Insurance Board) to report the injury which occured 10 days ago. Mr. Brown reported poor work conditions in the factoryand expressed concern regarding safety of machinery.. Mr. Brown reported that he had mininmal training prior to start his job.
Current Status: Mr. Brown is having trouble performing his personal care and ADLS (activities of daily living). His wife is also assisting him to perform ADLS (activities of daily living) (meal preparation, shopping etc.) Mr. Brown also reported decreased ROM (range of motion) at the site of his injury. He has large blisters and ++erythema to his surrounding skin.
Mr. Brown doesnot have any insurance and cannot afford to pay for his medications. Mr. Brown's recent BP (blood pressure) was 160/90 and Mr. Brown has been rationing his medication. Mr. Brown's GP (general practitioner) expressed concern regarding this practice. and provided Mr. Brown some samples of Norvascuntil Mr. Brown can apply for funding for his medication.
Mr. Brown reported that he completed his last dose of Zyprexa five days ago and is not able to refill the prescription because he is unable to afford for medication. Mr. Bron has experienced auditory hallucinations or suicidal ideations. M. Brown reported that he completed a course in anger management 10 years ago and found the course to be very effective.
Social: Mr. Brown is married with 3 children ages 5,4, and 6 months. Mr. Brown's wife was recenty laid-off from her job as a cashier and is receiving Employment Insurance. Mr. Brown currently lives in a apartment and has little to no saving. He is concerned about paying for his rent which is $2500 monthly along with food, clothes, and diapers for his infant son. Mr. brown will require surgery; however, he is concerned about missing time off work. Mr. Brown would like to return to work as soon as possible however Mr. Brown will require some time to recver from his surgery. The patient's surgeon recommended at least 3 weeks off work post-op.
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