Chief Complaint Postherpetic pain. History Patient is a 28-year-old right-handed white male who is a fair historian. He states that last July, he started having issues, which he ultimately blames on a shingles breakout. He states that he was doing some exercises with barbells and felt significant pain along the left T7 dermatome. He then developed significant pain there. He went to a local hospital. I think that time, it was Maine Medical Center. He asked for an MRI and was shown to have some straining of the musculature in the T7 intercostal area. He later developed herpes shingles rash in that area. He was treated with acyclovir, but by his report, was not put on carbamazepine at the same time. Since then, he has had lancinating …show more content…
The rest of the review of systems were reviewed and are negative. Social History He still smokes. He rarely drinks alcohol. Family History Cancer. Past Medical History Gastritis, postherpetic neuralgia. Allergies Penicillin, amoxicillin. Medications Omeprazole, Dramamine, Flonase, Sudafed. Examination Constitutional Weight 150 pounds. Height 5 ' 8". Respirations 12. Pulse 69. General He is in no obvious distress. Mental Status He is oriented x3, alert, cooperative. Good short-term, long-term, and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration. Cranial Nerves Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation, and movement. Tongue and uvula are midline. Normal auditory acuity. Normal shoulder shrug. Motor Was 5/5 all four extremities with normal tone. Sensory Was slightly decreased in the left T7 distribution. Also, he had a positive Tinel 's, when I pounded with the reflex hammer in the T7 root exit area just lateral to the spinal cord. Cerebellar Revealed good finger-to-nose, heel-to-shin, and rapid alternating motion.
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.
Family History also is positive for rheumatoid arthritis (Inflammatory changes in the joints causing pain), so we had serology (scientific study of blood or other bodily fluids) run for the erythrocyte sedimentation rate (the rate at which red blood cells settle in one hour used to detect inflammation associated with conditions such as infections, cancers, and autoimmune diseases), and looking for presence of Anti-Nuclear-Antibodies (found in patients whose immune system may be predisposed to cause inflammation against their own body
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.
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.
D-The patient was placed on HOLD to address her no show for last week. This writer asked the patient if she was okay with tomorrow 's appointment based on her appointment letter. The patient to do the session today since she 's already present and waited for this counselor. This writer agreed to conduct the session. Reports stable on her dose and deny the need for a dose decrease as she denies any cravings/withdrawals.
She also has difficulty staying focus on given task. She requires constantly prompting, close proximity, task adaptations, redirections, repeated instructions to remain focus and complete assigned task. After observing her three I-Ready Overall Scale Scores, there was an increased. Her Test 1 and Test 3 overall scores increased from 420-445. She made a 25
Activities at home and work worsen the pain. Numbness, tingling, and burning sensation are reported with increased pain throughout the week. The patient is requesting medication refills and reports limitations with gripping, grasping, pushing, pulling, and lifting 10 pounds. Activities of daily living are limited due to pain, as
He has also recently received part of a series of synvisc injections, which have helped somewhat. He reports increased pain since last
Normal fund of knowledge. Normal attention and concentration. Cranial Nerves Visual fields full to confrontation. Extraocular muscles intact. PERRLADC.
This is a 25 year old African American male who is here because he is experiencing burning secsation with urination, and irritation at the penus. Patient is also requesting stuture removed form his right hand. difficulty with Patient denies chest pain, SOB, N/V/D, or fever. Patient denies depressive moods, thoughts of suicide or homicide. current pain
Bob was cordial and compliant throughout the assessment. III. Background Information David and Ruth report a normal pregnancy with no complications with labor and delivery. Furthermore, they describe Bob as being an advanced baby having met all developmental milestones early.
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 a 53 year old male who presented to the ED via EMS intoxicated and reporting suicidal thoughts. The patient denies homicidal ideations and symptoms of psychosis. The patient endorses depressive symptoms including: tearfulness, isolation, and insomnia. During the time of the assessment the patient is awake, alert, cooperative, and clam. the patient reports that he had been drinking to 2 pints of alcohol earlier during the day.
The patient was diagnosed for polyps and multiple diverticula at the age of 68. The Patient suffers of painful osteoarthritis of both knees, shoulder hips. Patient?s mother deceased at the age of 79 from breast cancer and her father deceased at the age of 54 from heart attack. The patient noted with bilateral lower extremities edema, and claimed that she uses 2 pillows as a comfortable position to sleep,
The spastic diplegic subtype had the highest prevalence of registration patterns in comparison to the other subtypes, indicating that that do have some passive