Jimmie Bowman was seen in followup for CIDP, causing previous weakness and numbness of his distal lower extremities. He states that the strength of his distal lower extremities [____] continues improved and is staying normal. He has occasional mild feeling of numbness of his feet, but states this is staying down to what he can tolerate. He is not having pain of his feet. He is no longer on Imuran. He was on this previously for CIDP.
ROS: Genitourinary - History of BPH, for which he is on tamsulosin.
EXAMINATION: He continues awake and alert. He converses easily and appropriately. He is in no acute distress. Blood pressure 120/78. Pulse 70 and regular. Weight 177 pounds. Height 5 '6". 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. He had normal sensation to light touch, pinprick, and vibration sensation throughout both upper and …show more content…
He has no Romberg 's sign.
IMPRESSION: History of chronic inflammatory demyelinating polyradiculoneuritis. The strength and sensation of his extremities continues to improve after this, with no recurrence of symptoms from this with weaning off of Imuran.
PLAN: Continue off of Imuran. Continue observation from a neurological standpoint. Followup in one year to make sure he is not having any worsening of the strength or sensation of his extremities. I have advised him to contact me soon than this, though, should he have worsening of the strength or sensation of his extremities, especially of his distal lower extremities or other neurological difficulties before then.
Thank you for allowing me to participate in this patient 's care, Craig Johnson,
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Circumstance: Ayden will maintain contact with medical team monthly. Ms. Smalls (MHP) and Mrs. Wigfall (MHS) discuss Ayden’s recent medical appointments and therapy. Action: MHS report Ayden will start physical therapy at an outside clinic. MHP and MHS discuss Ayden receiving all therapy at the same clinic to reduce several therapy appointments during the week. MHP and MHS review reports given since last week.
Range of motion is limited with flexion and extension of 20 degrees limited by pain. Spurling test is positive. Sensation is diminished C5-C6 bilaterally. Diagnoses are cervical strain, bilateral C5-C6 cervical radiculopathy, and diminished sensation, C6 reflex bilaterally.
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He was a known heroin user and was in and out of treatment. You were able to see the track marks in both of his arms. His skin was cyanotic, pale and clammy, along with pinpoint pupils. The ALS provider struggled to get an IV due to the long term drug abuse, so his veins were not adequate. Also, there wasn 't a clear report on when the patient was last seen at his baseline and responsive.
He previously had facet joint injections but only with short term good benefit. He continues to take ibuprofen and Robaxin as needed. On examination of the lumbar spine there is pain on palpation over the lumbar paraspinals. Range of motion was full.
Both the ambulance and the police arrived at the scene and took him to Kings County Hospital but because of the long wait they went to Beth Israel. His aunt drove him and his girlfriend. At the hospital he complained about his shoulder and wrist on the left side. He doesn’t remember the hospitals instructions regarding follow up care and he never returned to the hospital. His record says he complained about back problems and that he refused immobilization but he did go to DHD Medical and Dr. Katzman.
The patient is in good overall health, and prior to injury remained active, participating in water aerobics and outdoor activities such as yard work. The patient currently wears splints to protect and support the wrists. In addition to the initial OT evaluation, the self-administered assessment The DASH was used. DASH stands for "Disabilities of the Arm, Shoulder and Hand."
was wearing a hospital gown, he looked exhausted, his gray hair needed to be brushed, and his skin was pale. He has oxygen therapy via nasal cannula, and needed to be adjusted on his face. His gown was pulled down some by the heart monitor he was wearing, and his blanket was falling off. The air compression leg wraps were compressing when I walked in the room. R.S. was unable to bathe himself, brush his teeth, or feed himself.
He had a pituitary tumor removed, an operation on his knee and metal pins placed in his hips. And his jaw was split into fine pieces in order to be expanded because of the acromegaly. Doctors Notes • Swelling of right knee. • Ulcerated sores on lower left leg. • Abnormal hormone levels.