Nursing Case Study

DOI: 2/2/2016. Patient is a 59-year-old female certified nursing assistant who sustained injury to her low back and right knee while transferring a patient. Per OMNI entry, she was initially diagnosed with right knee contusion/strain and lumbar sprain. She is status post right knee arthroscopic medial meniscectomy, medial condyle abrasion arthroplasty major synovectomy/3 compartments and lateral release on 07/31/16.

Per the PT note dated 10/17/16, patient is doing well with the exercises. However, pain in her right knee continues to be a limiting factor. She is much improved functionally and her pain has lessened Stretching to the right knee into either flexion past 120 degrees and extension past -2 are painful and limited. Patient has attended 12 visits.
Mcclurg, the patient presents for medications and therapy follow-up. Patient wishes to discuss: "Why I am having numbness to the lateral aspect of the right foot?." She had new medical problems diagnosed since her last visit. she now reports numbness to the right foot. No diagnostic tests have been performed in the interim. Therapy provided since her last visit includes physical therapy. Patient has benefitted from therapy by decreasing pain. There has been no change on the use of medications since the last visit. Medication is helping. Pain without medications is rated as a 9/10. Pain with medications is rated as a 5/10. Medications help by decreasing pain. She is out of medications and is requesting a refill at this