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.
Per medical report dated 06/16/2015 by Dr. Lemley, the patient complains of pain and dysfunction to bilateral hands/wrists. She has right greater than left discomfort in her thumbs with numbness. She states that cortisone injections do not help. She has focal
R/s on 12/21/2015, Mr. Schubert was admitted for pain in his knees and swollen feet. R/s Mr. Schubert is diagnosed with anemia, chronic knee pain, hypertension, gout, and chronic back pain. R/s it was reported that Mrs. Schubert had gallbladder surgery a couple a weeks ago. R/s it was reported that Mr. Schubert
History: The Pt had Left Total Knee Replacement (TKR) ON 06/03/2015, following immense pain due to degenerative joint disorder. Pt had been having the pain since little over 5 years, but since the past year it started being unbearable as per the patient. Past Medical History: Pt has a Past Medical History (PMH) of Degenerative Joint Disease (DJD), back pain, anxiety, depression, GERD and hypothyroidism.
On the other hand, let’s investigate a story on Dr. Atul Gawande a surgeon and New Yorker staff member, “More than a decade ago, I saw a young woman in the emergency room who had severe pelvic pain. A standard X-ray showed nothing. I examined her and found signs of pelvic inflammatory disease, which is most often caused by sexually transmitted diseases. She insisted that she hadn’t been sexually active, but I didn’t listen. If I had, I might have ordered a pelvic CT scan or even recommended exploratory surgery to investigate further.
I get nervous very easily, especially when I don’t know what’s going to happen and when the situation is not in my control. Professor Griffiths explained the background of the patient, Sally Jacob. Sally Jacob was a 65-year-old female who was going to have a right side femoral popliteal bypass. Her background includes having hypertension for the 15 years, DNC heavy menstrual bleeding, peripheral arterial occlusive diseases in the right leg, and complains of having nausea and vomiting following a procedure due to the anesthetic
She had gone to a psychiatric clinic. She seemed like a lady that was very unhappy and had a different way of seeing things in life. She had been suffering from unbearable back pain for the last 13 months. This happened after her fall when she had fallen and fractured her pelvis, coccyx, right elbow and three ribs. She had daily narcotic medication that only moderately helped her.
PER REPORTER: On 9-21-2015 Kaseyanna was brought to the Eupora Pediatric Clinic by her mom, Shamekia. The reporter said that Kaseyanna has injuies to her ankle and a broken leg. The reporter said Shamekia was unclea about where she was at the time of the incident and she was unclear about what had happened. However, the reporter said that Kaseyanna stated that she was playing on the cough and she fell. It was told by the reporter that inside of Kaseyanna’s chart t on 9-8-2014 she was seen at the doctor because of illness and a history sexual abuse was noted in her chart and history from an open case in the
My name is Katarzyna Budkiewicz and I am a chiropractor from the Great Chiropractic Clinic in La Habra. I am writing to refer Dane Danes for a physical therapy evaluation and co-management. The patient presented to my office with low back pain that radiates from his back down to the lateral thigh and down to the front of the knee over the past 4 weeks. His pain increases with standing. Ice, ibuprofen and stretching do not alleviate his condition.
Over the years, she has taken oxycodone for treatment of her back pain due to other pain medications not offering relief. Ms. Davis has been compliant with her medications since her accident and only has gotten refills as scheduled by her prescription. At the last visit, Ms. Davis mentioned she had run out of her 60 pill supply of oxycodone that was prescribed and that she needs a refill because her pain is preventing her from performing household chores. She thinks her son might be stealing her medication considering that she has not taken more than the recommended dosages. After her physician spoke with her about ways to prevent her son from taking her medication and the consequences of her son taking her medication, Ms. Davis refuses to take any action against her
DOI: 3/1/2005. Patient is a 64-year-old female service representative who sustained a work-related injury to her neck, back and bilateral shoulders due to repetitive work activities. She is subsequently diagnosed with degenerative disc disease and depression. As per progress report dated 1/14/2016, IW reports continued improvement. Medications such as Baclofen and gabapentin as well as home exercise program are proving effective in improving pain levels, function and range of motion and overall sense of comfort.
He notes ongoing weakness of both upper extremities. He complains of increased middle-back pain and low back pain which is now a 7/10 in intensity. He last attended physical therapy on 10/20/15. He was last seen on 11/10/15, at which time MD felt he had plateaued and reached maximal medical benefit and therefore formal physical therapy was discontinued. He received two lumbar epidural steroid injection treatments.
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.
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.