Also, she was seeing the neurologist for a workup of her episodes of loss of consciousness. She is seeing me today for followup after a concussion. She is from Florida and is expecting to go back in two weeks. The patient does have several episodes of loss of consciousness. She states she usually loses consciousness while she is lying down, but sometimes she will find herself on the floor and not knowing how she got there.
On 10/16/2015 I spoke with Brittany Shavers the 2nd Director at the operation. Ms. Shavers stated she had went outside to tell D'Andrea Franklin something when she observed on the smaller playground Kaylee attempting to get on a bike and was shaking terribly and then fell on her back. Ms. Shavers stated she yelled at Shanna Myers who was already headed toward Kaylee that she was going to call 911. Ms. Shavers stated she went into Nelda Shavers the directors office and grabbed the phone as she was tell Nelda that Kaylee was having a seizure on the playground. Ms. Shavers stated Nelda got up and went outside while she called 911.
Cranial nerves continue intact, including the extraocular eye movements being intact without nystagmus. Visual fields are full in both eyes. He had no papilledema or atrophy of either optic disc. Pupils react from 4 down to 2 mm, bilaterally brisk and round to light and accommodation. He continues to have good strength with normal bulk and tone throughout his extremities.
On 8/2/2015 SO EMT Perez was dispatched to FC-505 regaurding general sickness. SO EMT Perez knocked and announced his presence at the door and was greeted by the residents spouse and then to the resident in question, a Mrs. Barbra Myers. Mr. Myers stated that Mrs. Myers was feeling unwell for the past couple of days but today she was acting unusal and slurring/mubling her words and all around acting uncoordinated. Mrs. Myers seems to be somewhat disorientated but is answering all questions appropriatly. SO EMT Perez performed and assesment which revealed the following; Blood Pressure 148/72, Pulse 101, Spo2 96%, Mrs. Myers is very hot to the touch but does not appear to be perspiring, SO EMT Perez recieved a temperature reading from Mr. Myers '
Received a report on 10/7/15 stating Ms. McGinnis was not given medication properly and scoring a 0 on MMSE. Son, Michael McGinnis reported he gave her dose of Methadone because she was hurting. Ms. McGinnis admitted to WBMC on 10/6 with chest pain and hypertension. While on medical unit, she was confused, pulling the cardiac monitor off, yelling, screaming, cursing the nurses, disrobing, and refused meds. On 10/7 she transferred to Senior Care she remained until 10/28 3:30.
Patient is a 51 year old Caucasian female living alone in her own home. The patient has a history and current syntoms of geralized anxity disorder, social phoina and panic attacks, which she takes madications for and sees a psychrist 2-3 times per month in Havasu. Patinets lives with six cats and the house environment is somewhat cluttered. The patinet is orinally from Glendale, CA., has a brother in Palmdale, CA, who is stays in contact with sometimes. Pt has a daughter in Big River, who is not supportive of her, but has three grandchildren who visit her.
they will also report abnormalities to the contact people on the list should her medications seem to fail. This company has a great reputation and requires no contracts. They charge 22.00 per hour with a 3-hour minimum. Determining what the best time of day for her is important. It appeared that her hardest times were in the evenings.
The patient is a 52 year old female who presented to the ED via EMS with bizarre behaviors. Per documentation neighbors found the patient screaming in her house. Per documentation LEO found the patient attempting to drink a closed bottle of alcohol hand sanitizer fluid. Patient presents with disorganized thoughts and irrelevant subject matter when asked questions about behavior upon arrival. Nursing staff was asked about status before the assessment and reports improvements in the patient bizarre behavior.
She didn’t look as bright as the first afternoon I saw her and still reported hypotension and lightheadedness on standing. She now also had upper abdominal discomfort. As Mildred had a pulmonary embolism history, alarm bells went off in my head. I asked Mildred if her care team was addressing the problem and if I could do anything. Mildred didn 't ask me to talk to the medical staff and not being her health care proxy or wanting to overstep my boundaries, I didn’t.
Since she had the surgery and they chunk of skull/brain taken out this affected and made her nervous with her balance. With perseverance she was able to work back to a normal health and get some of her balance back. Buck and my mom are similar because they both were in a bad state of health, but with
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.
Patient’s primary care doctor stopped her oral medication due to nausea and vomiting; and her liver function tests were elevated. She does not know names, but the sleep aid and the oral medication for pain during the day were stopped. She tolerates the medications well. Patient shows no evidence of developing medication dependency. Patient does not feel the current medication she is taking adequately addressing her pain needs and would like to try a different medication.
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.
The client was hospitalized in the NICU for 12 days following these difficulties. The cause of the seizure is unknown and the client has not had any seizures since that time. The client is currently not taking any medications. The client’s mother speaks Spanish and English