DOI: 6/12/2006. Patient is a 56-year-old male skid maker who sustained a work-related injury to his lower back when he bent over to pick up a tubing and felt a pull in his back. Per the procedure note dated 03/12/15, the patient underwent right L4-5 and L5-S1 facet injections. EMG/nerve conduction studies dated 06/02/16 demonstrated right S1 radiculopathy. MRI of the lumbar spine dated 06/06/16 showed degenerative changes in the caudal lumbar spine with chronic disc degeneration and small right L5-S1 intra-foraminal disc herniation.
There is atrophy of the right calf. Current medications include gabapentin and Norco. IW was diagnosed with low back pain, lumbar disc annular tear, intervertebral disc annulus fibrosus tear, spinal facet joint arthropathy, lumbar discogenic pain. Treatment plan includes pain management referral and right L5-S1 Epidural Steroid Injection (ESI). Per verification to the PT facility, the patient has attended 2 PT sessions for the lower back from 04/22/15 through
Kasim Al-Mutar has an HR of 126, BP of 100/45, Temperature of 38.8 and severe RUQ pain associated with his last episode of vomiting that occurred 2 hours ago. His heart rate is slightly elevated and he is running a slight fever. He has been reported to be pale in appearance with dry mucous membranes. He has also been requesting drinks of water. Mr. Kasim Al Mutar has reported to the previous nurse that he has shoulder tip pain scored at 7/10.
Diagnosis 1: Acute pain related to surgical intervention evidenced by self reported pain Chris appeared uncomfortable, with a grimacing facial expression, he verbalised a stabbing pain on his left knee with a pain score of 4 out of 10. When Chris’s pain worsens, to a pain score of 7 out 10, his respiratory rate increases to 22 breaths per minute and his heart rate increases to 86 beats per minute, scoring an EWS score of 1. Ackley, Ladwig, & Makic, 2016 explained that increase heart and respiratory rate are physiological changes related to pain. Goals: • Relieve Chris’s knee pain • Chris feels comfortable and able to sleep properly Nursing interventions: Conduct a comprehensive pain assessment using OLDCARTS. The OLDCARTS pain assessment helps determine the onset, location, duration, characteristics, intensity and the alleviating and relieving factors of pain.
DOI: 6/3/2016. Patient is a 50-year-old male forklift operator who sustained injury when he was hit by a forklift. Per OMNI entry, he was initially diagnosed with neck contusion and crushing bruises. MRI of the lumbar spine obtained on 08/18/16 showed mild retrolisthesis of L5 on S1. Disc desiccation is noted with decreased disc height at L2-L3, L4-L5, and L5-S1 levels.
Case Presentation: A 12-year-old boy presented to his primary care provider (PCP) with a chief complaint of right-sided testicular pain and swelling. The swelling started to occur approximately five days ago, with gradual onset of pain. The pain has gotten significantly worse throughout the day he presented to clinic. He rates the pain as an 8/10. The pain occurs when the patient is walking, lying down, and especially when he is lying on his side.
Patient is a 63 year old male complaining of cough that may have started 15 years ago but worsened with in the past 5 years since moving from Vietnam to the U.S. Currently living in SF Valley with cough being at its worse in the morning, often dry cough, sometimes productive throughout day. Patient denies fever, exception being from illness. Occasional red blood, chest pain, back pain, SOB, and DOE. Patient has stated that he has difficulty filling lungs with air and that the cold makes him cough more, while “Teas” tend to help a little.
There is tenderness to palpation of the cervical paravertebral muscles. There is muscle spasm of the cervical paravertebral muscles. Diagnoses are cervical myospasm, cervical sprain/strain, and depression/stress. Treatment plan includes a trial of acupuncture 1 x per week for 6 weeks, trial of chiropractic treatment 1 x per week for 6 weeks, functional capacity evaluation (FCE) to further evaluate patient’s functional capacity and limitations, transcutaneous electrical nerve stimulation (TENS) unit in the form of interferential (IF)/Electrical Muscle Stimulation (EMS) unit and supplies, referral to psychologist in order to assist with patient’s stress, anxiety and depression, and X-ray studies of the cervical
In 1921, While vacationing at Campobello Island, Roosevelt was diagnosed with polio. One day on vacation after a swim, he went to bed very tired. The next morning he woke up with a fever and his left leg felt numb. By the following day he was partly paralyzed from the abdomen down. He was soon diagnosed with poliomyelitis, a inflammation of the spinal column.
I think he had a severe episode of labyrinthitis and the residual balance disturbances from that. MRI is pending with the results which the MRI was done about two weeks ago, but the results so far have not been available. I would continue the use of meclizine as needed. 2. He has nasal congestion that has helped with Flonase.
DOI: 4/30/2013. The patient is a 41-year old male maintenance technician who sustained a work-related injury to his right shoulder/arm from lifting ladders all day. As per OMNI, the patient is permanent and Stationary as of 8/23/2013 with future medical care to include medications, creams, and possible need for injections. As per office notes dated 7/13/16, the patient co complained of bilateral leg and feet pain, back pain, neck pain and low back pain. The patient’s pain is rated as 7 to 10; average of 8.
His gait improved slightly with modalities, like deep tissue massage, ultrasound and also some home exercises but the pain was still present. Roger lee kilfoil jr Therapist treated the gentleman with iontophoresis of 4% acetic acid using phoresor PM900 at 2.0 mA DC current for 20 min of a period of 2 weeks. The positive electrode was on midshaft of fibula, and the negative electrode over the Achilles tendon insertion bilaterally. After two weeks, the patient’s pain scale improved and after the third treatment the patient no longer need the assistance of the rail for the stairs. The fifth iontophoresis treatment, he was discharged from physical therapy, and reached a goal of decreased posterior heel pain.
The Chalder Fatigue Scale 3. VAS-F, had to give a score of average fatigue over the last week on 0-10 4. Hospital Anxiety and Depression Scale 5. European Organization of Research and Treatment of Cancer Quality of Life 6. EORTC Breast Module (BR23) 7.
Primary diagnosis: Late effects of musculoskeletal and connective tissue injuries (Amputation). Secondary diagnosis: Affective/mood disorders. Rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr The claimant was a 34-year-old man. Alleged disability: Bipolar disorder, amputation of the left arm, and sleep apnea. He reported that he wore a prosthetic left arm most days.
SEPSIS/SEPTIC SHOCK - 2013 Brittney Bonsall Xavier University July 27, 2015 Pathophysiology questions (50 points) Adv Nursing questions (85 points) Pharmacology (30 points) CASE PRESENTATION Emergency Department Mr. Roberts, a 72-year-old man, arrived in the emergency department unconscious, with stab wounds to the upper-right abdomen and lower-right chest that were sustained in his home while fighting off a burglar. The paramedics secured two large-bore intravenous (IV) catheters in his right and left antecubital spaces and infused Lactated Ringer’s (LR) solution wide open in both sites. An endotracheal tube was inserted, and ventilation with a resuscitation bag with 100% oxygen was begun. Pressure dressings to both wounds were secured. A 5-cm stab wound to his right lower chest and a 7.5-cm stab wound to his