Emergency Room Summary

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The claimant has a past medical history significant for diabetes mellitus, hypercholesterolemia, and benign essential hypertension. An emergency room visit on 03/02/2017 indicated that the claimant presented with a history of diabetes and hypertension with complaints of intermittent severe headaches that started 2-3 months prior the visit. He had complaints of dizziness and disorientation. He stated that he had a CT scan the previous year which did show an aneurysm that was not important. MRI 9 months ago showed no abnormalities. He rated pain as 6/10 in severity. His blood pressure was 171/102. The physical examination was unremarkable. He refused to have any ED work up and would like symptomatic treatments. An EKG dated 03/04/2017 revealed a normal sinus rhythm, left axis deviation, and an inferior infarct. A mental health provider statement completed by Dr. Neil Jacobson…show more content…
He was noted to be depressed with constricted affect and poor concentration. He stated that he was interested in receiving intensive stabilization care each day due to his inability to acquire his previous lifestyle-performing appropriate ADL 's and attending work. The claimant had partial hospitalization on 04/26/2017, 04/27/2017, 05/08/2017, 05/09/2017, 05/10/20147, and 05/12/2017. He reported feeling sad, depressed, and unhappy. He rated depression and anxiety as 9-10/10 in severity. The claimant continued to have mental health care for a severe episode of recurrent major depressive disorder as an intensive outpatient patient on 05/17/2017, 05/19/2017, 05/22/2017, 05/24/2017, and 05/30/2017. FMLA paperwork completed by. Dr. Jacobson dated 05/30/2017 and 06/19/2017 were reviewed for any medical information. FMLA paperwork completed by Regina Mathew, LMSW dated 05/30/2017 and 06/14/2017 were reviewed for any medical

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