The claimant has a past medical history significant for an acute depression, asthma, bilateral high-frequency hearing loss, diabetes mellitus type 2, and hypertension. The claimant had an emergency room visit on 05/22/2017 due to left leg cramping. It was noted that she had multiple symptoms including a headache, generalized weakness, arm tightness, unproductive cough, frequent bowel movement, and nausea. Laboratory results showed elevated glucose at 200 and low potassium level at 3.3. Chest x-ray showed no acute pulmonary findings. She was diagnosed with a viral syndrome. A follow-up visit was recommended. A visit note from Mary Grace Lasquety, MD (Internal Medicine), dated 05/22/2017, indicated that the claimant presented with headaches since the …show more content…
It was noted that the claimant presented to the ER with complaints of a headache and fever. Urinalysis showed urine pH of 8.0 with squamous epithelial cells of 31-50/LPF. She had elevated glucose at 126 with low levels of BUN at 6, potassium at 3.3, sodium at 135, and chloride at 95. She was diagnosed with a viral syndrome. Zofran and a follow-up visit were recommended. A visit note from Dr. Lasquety, dated 06/01/2017, indicated that the claimant presented with daily headaches with an upset stomach. She also had an underlying depression from a long time ago and was treated with Zoloft. Her temperature was high at 99.4. A referral for psychiatric counseling was recommended. An initial assessment performed by David Williams, PsyD (Psychiatry), dated 06/30/2017, indicated that the claimant presented with depression. She had low comprehension. She was diagnosed with a moderate-severe depression. Individual therapy was recommended. The claimant had another assessment performed by Jack Joachim, NP (Psychiatry), dated 07/10/2017. It was noted that she was diagnosed with generalized anxiety disorder and depression. Medications and individual therapy sessions were
R: Client presented well groomed and calm. His mood was euthymic, and his affect was within normal limits. Client’s thought processing was goal directed and coherent while being instructed on LAMP VASH referral. Client reported being worried about meeting his VA claim appeal dateline.
R/s Tracie Antonelli receives hemodialysis. R/s Mrs. Antonelli has hypertension, anemia, iron deficiency, vitamin d deficiency, and a magnesium disorder. R/s Mrs. Antonelli is the primary caregiver for her 16 year-old disabled son, Dominic. R/s there is a concern for Mrs. Antonelli’s overall health if she doesn’t take her treatments. R/s Mrs. Antonelli’s husband, Vincent and other son, Anthony also live in the home.
I: CM guided client through ISP goals. CM inquired about client’s upcoming LAMP VASH appointments. CM discussed and encouraged client to get his driver’s license. CM praised client for being honest regarding drug use but also encourage sobriety. CM administered Beck Depression Inventory and review results.
A-Based on this writer 's assessment, the patient appeared to be alert and oriented. No evidence of SI/HI. P-Next appointment is scheduled on 07/1/2016 at 11am. Patient is aware about being placed on HOLD for the counseling
On 9/28/2015client met with Dr. Shuster and she was diagnosed with: Axis 1: Post traumatic stress disorder; 309.81 (primary), symptoms regarding the traumatic event in Columbia. 2. Mild neurocognitive disorder 331.83, rule out in light of the reportedly forgetting appointment, and being unable to recall any of 3 objects, needs neurocognitive testing to rule. No medication was prescribed and in the event that the client agrees to see a therapist Dr. Shuster will issue a referral, and if client memory becomes more of an issue client should be re-assessed for safety.
The claimant is an 18- year old filing a continuing disability review alleging depression and anxiety. The claimant has a history of anxiety and depression. She completed the SSA 3368 on 7/18/16 and indicated on the form she had not seen anyone for mental health but had a visit scheduled on 7/19/16. The DDS was unable to obtain additional information regarding the claimant’s conditions.
The SC enquired about Pa use of medical services or health status changes. The Pa reported no hospitalization, ER visit or new health problems, or medication change. The Pa reported that he saw his PCP a few weeks ago. The SC inquired about any changes in his functions. The Pa reported no change to his ADLs/IADLs, cognitive, social, emotional, or financial status.
Patient denies, fever, chill, vomiting, SOB, dysuria, frequency, or urgency. Due to symptom her PCM recommmend that she walk in during the hours of 11 yo 1130. Patient agreed and verbalized understaning to the POC.
D-This writer met with the patient as he arrived late to his counseling session. Reported stable on his current dose and denies the need for a dose increase when offered by this writer. Patient reported of his confidence of producing a negative UDS result for the month of October and the next following months afterwards as he declared, " I haven't been using." This writer asked the patient about the status of the IOP. Please note, the patient attempted to avoid the question by discussing his new employment with XL Center.
A-Based on this writer 's assessment, the patient was emotional, but eventually calmed down. The patient remained well-mannered, oriented, and alert. There was no evidence of SI/HI. P-The patient will adhere to the program policy and her next scheduled appointment is scheduled on
The following is my report of a patient, Mrs. Smith, who I examined this afternoon: Symptoms Mrs. Smith told me she was born in New Guinea and has been living in the United States for the past twenty-five years. She has had no major health problems noted in her history, and prior to her recent medical issues she has maintained good health. She came in presenting common symptoms of some type of neurological disorder. She had trouble walking, and she told me that her coordination was diminishing. I could hear that her speech was somewhat slurred, and she indicated that she was having trouble chewing and swallowing.
The patient is a 70-year-old female who is brought to the emergency room by her doctor because she has a decubitus ulcer nuclear. The daughter states clearly that she can no longer care for her mother. The patient's medical history is significant for hypertension, diabetes, previous CVA (which left her with left-sided weakness), and coronary artery disease. Her medications include antihypertensive medicines, as well as Plavix. Her physical exam reveals her to have left-sided weakness.
Ms. Lucas dos not appear to be responding to any internal stimuli. During the time of the assessment Ms. Lucas presented a wake, 4x oriented, appropriate speech, guarded, tearful, flat affect, and minimal eye contact. Ms. Lucas reports feeling guilty about her collegiate experience "turning bad" with the loss of her volleyball scholarship due to unknown reasons last year. Ms. Lucas reports today she has been experiencing several things that had influenced her mood.
1) I took responsibility for a full patient load during the last few weeks. I was responsible for doing a head-to-toe assessment, administering medications, and charting. I was responsible when contacting the necessary members of the interdisciplinary team, such as PT/OT, SW, the care home, the laboratory, or the MRP. I also spoke with family members in person and over the phone. I maintained patient confidentiality by not giving any identifying information over the phone, and stayed within my scope of practice, identifying to the family members that they would have to wait to speak to the physician to find out certain information.
For a demographic and diagnostic distribution of this sample, please see Table 1. As Table 1 shows, the vast majority (about 80%) of patients participating in the study met the criteria for a DSM-IV Axis I disorder, and the majority of patients (about 65%) met the criteria for either an anxiety disorder or a mood disorder. Patients were accepted