Follow up ER visit for back pain.
The patient is a 59-year-old female who tells me in early June she was moving a rolling coffee table at home. She states she felt a twinge in her back and had pain that radiated down into her left leg. She does tell me she had similar symptoms years ago when she was working at a different job. She was diagnosed at that time with a herniated disk and did have steroid injections and was out of work for six months. She tells me since then symptoms have come and gone, but this was the worst case of it she has had for quite some time. She was given both Percocet as well as Valium in the Exeter Hospital Emergency Room and does tell me she took these and completed them. She currently is just taking ibuprofen. Overall, her symptoms are improving. She does tell me that she has noticed some …show more content…
She does ask for more pain medication, but states Ultram worked well for her. She tells me she was given one of these in the emergency room. I did give her a prescription for Ultram 50 mg one to two tablets every four to six 6 hours p.r.n. #20 given with no refill. I did suggest we could try physical therapy, but she states things are improving and thus she does not want to do this.
The patient does have a history of irritable bowel syndrome and does request a refill her of her dicyclomine. This was given.
The patient was diagnosed with asthma in her 40s. She is a smoker. She does use albuterol very infrequently. She would like a refill of this and this was given to her. She does tell me she had pulmonary function tests in the past, but I do not see any results of these in her chart. May want to consider ordering baseline pulmonary function tests at her next appointment.
Healthcare maintenance. The patient is scheduled for a physical in October. She will do her blood work prior to
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R/s Mrs. Antonelli was hospitalized at the end of May for an overload of fluid due to her not taking her treatments. R/s Mrs. Antonelli was hospitalized again in June. R/s if Mrs. Antonelli doesn’t take her treatments she will become confused and lethargic and also toxic can build up her in her body R/s Ms. Antonelli has to come
On 12/11/2015 SO EMT Perez was dispatched to CT-616 regaurding a fall. SO EMT Perez knocked and announced his presence at the door and was verbally invited in by the resident. The resident, a Mrs. Joan Buckalew was lying supine by the side of her bed. Mrs. Joan Buckalew stated that she had slid of the bed and onto the floor and was unable to get up on her own strength. Mrs. Joan Buckalew stated that she was currently seeing Dr.Putamunda at the medical center and also states that it has been a year since her last fall.
While auscultating sounds of lung fields no wheezing was found, and VS were within normal range for patient as determined through comparison of chartings on 10/23/2015 thru the morning and lunch VS of 10/26/ 2015 before impaired gas exchange was detected. 10/26/2015 2. Administer O2 @ 2L N/C
Jean Russell of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with Flavia Tocco and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. INTERVIEW SETTING I met Ms. Tocco at the St. John’s physical therapy department. Ms. Tocco was open to providing me information on her current and prior medical history.
CAMO Handoff. Two patient verifier used to confirm name and DOB. The patient states that she has a hx of diverticulitis and she believes that she may be having a flare up. The patient states that since this morning she has been having pressure to her lower abdomen with 4/10 dull constant to he entire abdomen and bilateral flank pain. Patient states that she have not eating anything this morning but tolerated dinner last nigt.
She did complain of some left face problem, left neck pain, headache, left shoulder and arm pain. She was seen in the emergency room for this. Her neck CAT scan revealed decreased disk space height at C5-6, C6-7, but no fractures. Head CAT scan was normal. She presented to her PCP couple of days later complaining of uncoordinated gait, headache, nausea, and her left arm being "on fire".
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.
I attached the therapy notes on Ms. McMahan from May 23rd and 24th. I did not see any current notes for June. She continues to be nonbearing and transfer from bed to chair with a total lift. The following is the RN Case Manager assessment on 06.15.2017: Pt was observed sitting in her w/c in her room at Victoria Gardens Rehab.
Pathophysiology “ Multiple sclerosis cam be defined as an autoimmune disease that affects the myelin sheath and conduction of pathway of the nervous system (CNS). It is one of the leading causes of neurologic disabilities in young adults. It is a chronic disease that is characterized by periods of remission and exacerbation.” (Ignataviscius & Workman, 2013, p. 978) Multiple sclerosis affects all patient’s differently, progressing at different rates over different periods of time.
Her other symptom is that of a reduced exercise tolerance. She finds that when she walks up the stairs at work, she has some muscle pain in her quad and significant fatigue that she does to attribute to shortness of breath on exertion. It is not associated with any chest pain, palpitations or dizziness. On examination, she is well looking, she was saturating at 98% on room air and her lung fields were clear. Her cardiovascular was unremarkable.
She advised she discussed options with her doctor for relieving this pain and treatment. She made it clear that she would not have an operation or other procedure on her back as she believes this would only make things worse. She stated that she doesn’t see much she can do for her pain other than what she has been doing in the past. The things she has done in the past are using aspirin and walking to keep in shape. She explained that her doctor agrees with her
She complained of gradual development of painful swelling and erythematous skin rashes over her face, neck, hands, chest and upper back. She also complained of gradual difficulty rising from sitting, climbing stairs and combing her hair. Symptoms progressively increased over time and she was unable to carry out her daily chores. She described symptoms of progressive dysphagia for solids. There was no history of weight loss, fever, and shortness of breath, oral ulcers, arthralgia, and