DOI: 07/27/2006. Patient is a 36-year-old female apprentice engineer who sustained an injury to her neck and back due to lifting of hall demolition debris. Per OMNI entry, she is diagnosed with chronic back sprain/strain. Urine drug screen obtained on 04/05/16 revealed positive for hydrocodone and Flexeril. Per the progress report dated 09/06/16, patient complained of low back pain.
DOI: 2/6/2003. The patient is a 46-year old female aide who sustained a work-related injury to her low back while she was transferring a high school student from wheel chair to table. MRI of the lumbar spine dated 2/19/16 revealed T12-L1, there is no focal posterolateral right disc protrusion; L1-2, no posterior disc protrusion/osteophyte complex; L2-3 , no posterior disc protrusion/osteophyte complex; L3-4, there is lateral left disc protrusion/osteophyte complex; L4-5, there is an approximately 3 mm posterior disc protrusion/osteophyte complex; and L5-S1, there is mild posterior disc/osteophyte complex. As per office notes dated 3/30/16, the patient has gradually improved but is still not back to baseline pain. Prolonged standing exacerbates pain.
YPP/AWOL: The patient missed group yesterday as she reports that she had overslept and was unable to dose. The patient AWOL twice in a week and signed a AWOL notice as the patient is aware about the risk factor of missing a dose which can lead to a relapse. The patient admits about relapsing and used heroin by IV- 5 bags. The patient reports that because she missed her dose twice, she began experiencing withdrawals such as sweats and cramps. This writer proceed to complete a dose change request upon the patient request to increase her dose by 5mgs.
The patient used a four poster walker after the spinal surgeries in 2010 and then graduated to a cane after hardware removal in late 2012. He is now taking Norco 5 mg 4 times daily. He has not had any physical therapy in the last two years and does not recall being given home exercise program from physical therapy. He is not doing home exercises. He has not had any epidural steroid injections and chiropractic treatment for the last two years.
Fleming et al. performed an experiement, The Gastrocnemius Muscle is an Antagonist of the Anterior Cruciate Ligament, to determine the relationship between gastrocnemius muscle contraction and ACL strain. The participants were 4 male and 2 female subjects who were scheduled for an arthroscopic menisectomy or chondral debridement but had no current or previous ACL injury. The subjects’ ages ranged from 38-56. On the day of each subject’s surgery, the patient was given a spinal anesthetic to relax the muscles of the legs.
In the ER the patient has stated that few days before admission he has lost consciousness and fell to the ground, however do damage was caused by the fall. After admission the patient had the fallowing testing performed Lexiscan Stress Test: No EKG evidence for Ischemia Chest X-Ray: Heart & lung clear, no evidence of consolidation, pleural effusion, pneumothorax Cervical Spain CT: bones are normal, soft tissue normal , no abnormalities detected on any structures
He is status post cervical discectomy with fusion at C4-6 on 3/12/14 and a suboccipital craniotomy and decompression of a C1 lamina due to Chiari malformation on 12/29/14. Per medical report dated 06/30/15, patient presented for low back pain with left anterior leg pain. He has not tried PT or injections. He does have weakness in the left leg. At times, he is unable to put pressure on the left side.
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".
DOI: 1/24/2008. Patient is a 57-year old male medical assistant who sustained injury to her neck and right shoulder due to performing normal work duties. Per OMNI, he was initially diagnosed with cervical radiculopathy and stenosis. He was declared P & S by primary treating physician Dr. Chan on 07/23/09 with 9 % permanent disability (PD). Future medical care includes MD visits, ESIs, acupuncture and medications.
The book “Fibromyalgia for Dummies” recommends that fibromyalgia patients should find out what helps them fight their pain the most so that they can decrease their pain levels. A big improvement in a patients daily life would be to incorporate exercise their daily routine. “Fibromyalgia for Dummies” recommends slow exercising because fibromyalgia patients may become overtired quickly if they exercise at a “normal” persons exercise rate. A rheumatologist is usually the doctor to diagnose fibromyalgia. A rheumatologist is an internist meaning that they specialize in diseases of the
DOI: 1/16/2015. Patient is a 66-year old female assembler who sustained injury when she slipped on ice, caught herself and hurt her knee. Per OMNI, she was initially diagnosed with right knee strain. MRI of the right knee obtained on 07/07/15 demonstrated a tear of the anterior horn of the lateral meniscus. The root of the posterior horn of the lateral meniscus is attenuated as well which may represent a degenerative tear, although the ligament of Humphrey is relatively prominent and this may represent a normal variant.
Scenario: A 13 year old female is admitted to acute care for sickle cell crisis. The patient has an accessed port with maintenance IVF running and has a Dilaudid PCA for pain. The patient develops a fever of 103 and has a white blood cell count of 18 on recent labs. Due to the patient having a central line, fever, and increased WBC the patient triggered a CLABSI score of 3 on the watch list and antibiotics are not ordered. Per protocol, the paramedic notifies the bedside nurse and the attending physician of the CLABSI score so that appropriate antibiotics can be ordered.
DOI: 01/05/2004. Patient is a 64-year-old female nurse who sustained a work related injury to her cervical spine, lumbar spine, and bilateral shoulders during the course of performing her normal job duties.She is statius post bilateral L4-5 and L5-S1 facet blocks with fluoroscopy on 10/23/12. MRI of the lumbar spine dated 01/08/16 revealed moderate levoscoliosis; L1-L3 2-3mm posterior disc protrusion; L3-L4 4-5mm pseudo and/or true posterior disc protrusion; L4-L5 3-4mm posterior disc protrusion/extrusion; L5-S1 2-3mm posterior disc protrusion. Based on the progress report dated 05/19/16, the patient presents for a follow-up orthopedic re-evaluation. She states that she finally got her Voltaren 1 week ago and she noticed that she has been able to walk with less
MeniscocyLosis (Sickle Cell Anemia) The severe pain in the patient’s joint were described as being on fire times 100. She was fatigued and could barely move. As a result of this erratic unbalanced physical condition, the patient came into the hospital emergency last month complaining of abdominal pain along with spiking body temperatures ranging between 99.0 to 102.0 degrees Fahrenheit. This recent problematic condition is new. Reading through the patient’s records, it was discovered that she came the month before with a chronic infection which was treated with the strongest doses of penicillin allowing the patient to recover within ten to fifteen days.
Patient is a 67-year-old right hand dominant female maintenance who sustained injury to her left shoulder due to continuous trauma from 04/04/00 to 04/04/01. Per OMNI, she was diagnosed with rotator cuff tear of the left shoulder. She is status post left shoulder arthroscopy and one manipulation. She was declared P & S by Ortho AME Dr. Fernandez on 06/11/04 with 28% permanent disability rating. Future medical care includes doctor visits, medications, PT, injections and no additional surgery anticipated.