CC Mrs. Bailey is a 38-year-old female here today complaining of paresthesias of her lower legs. The patient tells me since last Thursday she noticed that there is a different sensation to both of her lower legs. She says she first noticed it Thursday when she was shaving her legs in the shower. It was not until she touched the leg with the razor that she was aware that it had just a different sensory feel. She said since then she has noticed this "weird, numb feeling" in the lower half of her body, she notes that from the lower buttocks down her legs. The only area that she feels pins and needles sensation is in her feet intermittently. She says that both legs are affected equally, but she feels it more to the medial side of the legs than to the lateral sides of the legs. Since it has started, it has remained stable. It has not worsened, but it has not improved as well. She has had no …show more content…
We did talk about options and at this point, I think this does deserve further investigation and we reviewed options. She is going to start with some laboratory studies, which she plans on doing today and I should have the majority of them back before the end of the week. We talked about further evaluation with nerve conduction studies as well as the possibility of an MRI and neurology consultation. At this point, she was comfortable with starting with the labs and doing the testing in a stepwise fashion. She was advised in no uncertain terms that if her symptoms worsen acutely, with any progression of her neurologic symptoms, she is to seek care immediately at the emergency room and she is aware of what to be watching for. She plans on contacting me by the end of the week for the results of her testing and further investigation will be decided from there. She does voice understanding of these recommendations and was with comfortable this. All questions
2. EMG/NCV studies consistent with peripheral motor and sensory neuropathies, from October 2008 12/15/15 Progress Report described that the patient has ongoing low back pain. He was last seen on 10/28/15. The patient stated that his current medication regimen has been helpful. He rated the pain 9/10-scale level, which is brought down to 6/10-scale level with the medications.
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.
Pain is located in the low back and left leg, rated as 4/10. There is associated numbness to the left thigh and foot, and pins and needles sensation to the left foot. He continues with Percocet with 80% help with use. CURES was very consistent and appropriate.
Ms. Cardiello reported that she also suffers from moderate to severe anemia. Ms. Cardiello reported that she get IV infusions of iron every 8 to 12 weeks, she indicated when she experiences pain she takes
After a few years, there was a tumor in her pituitary region. The tumor was secreting excessive amounts of growth hormone, casing symptoms to appear. She had enlarged hands and feet, coarsened, enlarged facial features, coarse, oily, thickened skin, and
She had a computed axial tomography scan done which was negative, was referred to neurology and was taken out of work for 2 months. She is currently getting Botox injections every 4 months which is helping her headaches and associated neck problems as well. Her neck problems seem to be worsening over time. They are more obviously dysfunctional when her Botox relieves some
Gait Markedly antalgic. Equivocal Romberg. DTRs 2+ in the upper extremities and knees, trace at the ankles. Labs/Studies CAT scan and C-spine are as noted
Jean Russell of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with Flavia Tocco and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. INTERVIEW SETTING I met Ms. Tocco at the St. John’s physical therapy department. Ms. Tocco was open to providing me information on her current and prior medical history.
Higgins was diagnosed with Multiple Sclerosis when she was in college around twenty two years old. She was suffering from loss of vision and horrible migraines. She had a vision test, an MRI, and then a spinal tap. The MRI showed four lesions on her brain and the spinal tap confirmed the diagnosis because her spinal serum tests differently than healthy humans. Every month Higgins has an injection of medicine that is meant to help slow down the progression of her MS.
She will follow up in one to two weeks with Dr. Murray or myself with sooner follow up as necessary. She is aware of what to watching for in the meantime. If she does develop any new symptoms or concerns, she will contact me so we can address each issue as they arise. She does understand also down the road, further evaluation with CT may be necessary, if her pain persists. All questions answered in the office
SOAP Evaluation 1. Sign and symptoms/Clinical presentation of disease process a. How did your patient present: 62 y.o. white, female patient with past medical history of hypertension, diabetes mellitus, hypercholesterolemia, hypothyroidism, and obesity presented with chief complaint of a painful vesicular rash on her back down to her waist. “The rash is very painful. It’s a continuous stabbing, burning pain.” She rates the pain 8/10.
Basically she has focal seizures. They are not generalized, limiting duration and not associated with headaches, dizziness or visual disturbances, no vomiting and no other associated symptoms. Mostly she is noted to have a long-standing history of bipolar disorder followed by psychiatry as an outpatient. The patient
We are able to make that conclusion by the fact that she doesn 't walk like before and often takes pain medication. 2. A recent argument that I had was with my boyfriend josh was he was watching a prison movie. Josh made a comment about how inmates were acting gay. I told him " it 's logical that inmates will act gay in prison when they haven’t done any
Review of Symptoms General: denies fever, night sweats, significant weight gain or loss, exercise intolerance, depression, sleep disturbances, or fatigue HEENT: denies dry eyes, irritation, vision changes, difficulty hearing, ear pain, sore throat, runny nose, or sinus pressure Neck: denies swollen glands or stiff neck Pulmonary: denies cough, wheezing, or shortness of breath Cardiovascular: denies chest pain or palpitations Gastrointestinal: denies abdominal pain, nausea, vomiting, diarrhea, constipation, acid reflux, or melena Genitourinary: reports dysuria and vaginal itching, denies incontinence, hematuria, increased frequency, abnormal bleeding, or vaginal odor Musculoskeletal: denies muscle aches, weakness, joint pain, back pain, or edema Integumentary: denies any rashes, lesions, or change in hair Neurological: denies numbness, headache, seizures, tingling or sensation changes Endocrine: denies bruising, excessive sweating, thirst, hunger, heat or cold intolerance Objective Data Physical Exam Vitals: blood pressure - 130/77, heart rate - 97, respiratory rate - 17, temperature – 97.9 , oxygen saturation –97% on room air, weight – 183 pounds, height – 5 feet 4 inches, body mass index –
Although in MS, the spinal cord signs are asymmetrical involving only a part of the long ascending and descending tracts, i.e., paraplegia and complete sensory loss are not usual. Clinical sings include: a rapidly evolving symmetrical or asymmetrical paraparesis or paraplegia occurring over several hours or days, ascending paresthesia, loss of deep sensibility in the feet, sphincter disturbance, and bilateral Babinski sign. An infectious illness is reported from some patients preceding the onset of the symptoms. In this case a postinfectious demyelinating disease is more likely to happen rather than