Emergency Room Visit Summary

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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

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