DISPOSITION: Discharged to home. The patient and her husband were given detailed written instructions as to her activities and limitations. I will follow her in my clinic in 6 weeks’ time and I have advised her to stay off work until that time. No lifting. She was given a prescription for Tylenol with codeine PRN pain. She was advised that if any problems developed i.e. fever, nausea, vomiting, headache or blurred vision she is to come to clinic earlier or report to Hillcrest Emergency Room.…
Ms. Hollar’s neck was examined and the records state that the examination was negative for injury or acute deformity. The neurological examination was negative for altered mental state and loss of consciousness. A CAT scan and x-rays were negative. After the accident the plaintiff was seen by Dr. DaRoach and the doctor noted, “ She has no pain going to lower extremities, no weakness in the upper extremities and denies any headaches/blurred vision/weakness in legs.”…
12/16/15 Progress Report documented that the patient has left foot pain, which is described as stabbing, aching pain, which shoots up the leg with excessive walking and standing. The patient benefited greatly from a sympathetic nerve block. She was able walk and sensitivity of the foot was restored. The pain is rated 3/10-scale level with medications. There are no side effects, no aberrant behavior to the meds. The med provide good pain relief. She is currently taking Oxycodone, Norco and Gabapentin. The musculoskeletal exam revealed joint pain, swelling, muscle cramps, muscle weakness and stiffness. Treatment plan included Sympathetic nerve block for RDS. Follow-up is in 1 month.…
B) was brought into the emergency room for pain to left leg and left hip. The injury occurred when the patient had a fall due to him losing his balance after tripping over his dog. The hospital is a 60 bed rural hospital located in Mr. B’s hometown. Mr. B was brought in by his son and neighbor. Upon triage Mr. B was complaining of pain 10/10 on the numerical pain scale and his vitals were found to be stable. Mr. B has a history of impaired glucose tolerance, prostate cancer, and chronic pain which he is on oxycodone. The Patient states he had no known allergies or previous falls. Upon the nursing assessment Nurse J. has noticed that the patient has limited range in motion, his left leg has swelling and appears shortened in comparison to the right. Nurse J. has informed the ED physician which he came to his bedside for…
Her muscle testing for the left upper extremity is 5-/5. Right upper extremity strength is 4/5. She requires moderate to maximum assistance with activities of daily living and transfers. Impression includes mobility and self-care deficits secondary a fall with progressive cervical myelopathy, status post 09/06/16 posterior decompression and fusion at C3-7; neurogenic pain; and increased risk of deep vein thrombosis. It was noted that because of her mobility and self-care deficits, she requires 24-hour rehabilitation nursing care. MD will obtain bilateral venous surveillance Dopplers of the lower extremities. Patient will be instructed on how to do heel pumps. She will be seen by PT, occupational therapy, rehabilitation nursing, case management and physiatry. She will undergo interdisciplinary rehabilitation receiving therapy at least 3 hours a day, 5 days a week. Ultimate goal is to obtain a level of modified independence in all activities of daily living, transfers, ambulation, and assistive device to increase her strength and endurance and get back home safely with the husband. Estimated length of stay is 18-21 days. She will continue on Norco and Percocet. Lyrica will be added for neurogenic…
Physical Examination Results: Patient shows signs of muscle loss an deformity, an awkward gait, and difficulty breathing.…
PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished male who appears to be in moderate distress, with pain and swelling in the upper left arm. Vital sign: Blood pressure 140/90, temperature 98.3, pulse 97, and respiration 18.…
Myelin visited my office yesterday complaining of numbness in his right leg and face. He has also been experiencing muscle weakness and mild depression. I noticed a delay in his visual response in both eyes. I have referred Myelin to your facility because of possible multiple sclerosis, and I am requesting an MRI of the brain and spine. Please fax the results to me as soon as possible.…
IW reports constant neck pain as aching with exacerbations and radiation to bilateral shoulders/upper extremities. IW notes intermittent numbness and tingling to bilateral hands/fingers. IW reports major weakness in the upper extremities, not being able to grasp items and involuntarily drop items. IW reports being able to tolerate right wrist pain. IW reports exacerbation of pain due to change in weather. IW complains of headaches with dizziness and nausea. She attempts to avoid any exacerbating activities. The IW has tried pain medications and therapy which helps some. Her sleep quality is poor secondary to pain. She has a history of epidural injections with no change. She has been doing PT 3 days a week since her last visit with some improvement of symptoms. On examination of the cervical spine, bilateral paracervical and trapezius tenderness is noted. Bilateral palpable spasm is noted. Range of motion (ROM) shows flexion of 35 degrees, extension of 20 degrees, and bilateral rotation to 55 degrees, all with pain. On examination of the lumbar spine, bilateral paralumbar tenderness is noted with palpable spasm. Sacroiliac joint tenderness is noted, right greater than the left. ROM demonstrates flexion of 45 degrees and extension of 0 degrees, all with pain. Straight leg raise is positive bilaterally. Sensory…
HISTORY OF PRESENT ILLNESS: The patient is an elderly female who fell four days prior to admission. He noted immediate pain and swelling in the area just below his left elbow. He presented to the emergency room for treatment.…
A patient presented to the Emergency Department with the complaints of hip and leg pain. The patient rated the pain 10/10 on the standard pain scale. His (L) leg appeared shortened with swelling, ecchymosis, and limited range of motion. The leg was stabilized and then he was further evaluated and discharged to a room in the nursing department. The patient was also noted to have a history of impaired glucose tolerance and prostate cancer. The patient’s current medications were atorvastatin and oxycodone for chronic back pain. The patient was placed in a room and prepared for a procedure. The physician evaluated the patient and proceeded to order Valium, when unsuccessful hydromorphone was ordered. The patient had not achieved appropriate sedation for the procedure and additional medication was ordered. The patient was not placed on a cardiac monitor and a baseline oxygen level was not obtained prior to the administration of sedatives. The patient was receiving “Conscious sedation” in order for the physician to perform a manipulative procedure. The patient eventually had a decrease in oxygen saturation and became hypotensive- an arrest occurred. The patient was resuscitated and then transferred to a tertiary center. The patient was found to have brain damage and after…
PHYSICAL EXAMINATION: Revealed a pleasant but depressed appearing female who is over weight but in no acute distress. She wears a brace on her right wrist. Height is 5 feet 7 inches. Weight 252 pounds. Temperature 98°F. Pulse 80. Respiratory rate 20. Blood pressure 140/80. She has not carotid bruits or meningismus. Cranial nerves 2 through 12 are intact and detailed to include visual fields. Funduscopic exam and pupillary examination. Motor exam reveals 5 out of 5 strength in arms and legs without atrophy or vesiculation. Reflexes are trace over four. Sensory exam is negative and nonfocal.…
HISTORY OF PRESENT ILLNESS: The patient is an elderly male, who fell four days prior to admission. He noted immediate pain and swelling in the area just above his left elbow. He presented to the emergency room for treatment.…
As evidence by: Patient complains of fatigue; walked short distance with 4 wheel walkers and 2 people assisted. Patient had pain at the shoulders, hardly moved himself or transfer from bed to wheelchair.…
The patient wears clothing that is conducive to the weather. No body odor or breath odors noted. The patient appears to be clean. He is wearing slippers when he is inside the cell. He has trimmed nails both in hands and feet. No discharges from the ears and nose noted. Minimal hair noted on the chin. His skin is smooth and warm to touch with no bleeding, lesions, ecchymosis noted. Hair is present on his axillae. The client’s stated chronological age is congruent with his apparent age. Client is able to walk independently without any assistance. He has an appropriate gait. He appears to have a slouching posture while standing, walking, and sitting. He has slow but purposeful movements. He has difficulty picking up things from the ground while standing. He is having tremors specifically in his both hands and right feet. He always moves his feet in a walking manner whenever he is only standing.…