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.
The claimant has a past medical history significant for an acute depression, asthma, bilateral high-frequency hearing loss, diabetes mellitus type 2, and hypertension. The claimant had an emergency room visit on 05/22/2017 due to left leg cramping. It was noted that she had multiple symptoms including a headache, generalized weakness, arm tightness, unproductive cough, frequent bowel movement, and nausea. Laboratory results showed elevated glucose at 200 and low potassium level at 3.3.
Introduction: Client My patient, MG was a 72-year-old female who came to the emergency department because of a fall in her bathroom. Her admitting diagnosis was a right hip fracture. Other concurrent health challenges she had were: hypertension (HTN), high cholesterol, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD). MG was a full code status with no known food or drug allergies.
Assessments include myositis, low back pain, thoracolumbar and lumbosacral intervertebral disc disorder, muscle spasm of the back and lumbar radiculopathy. He was given a prescription for Flexeril and Toradol. Toradol 60 mg injection was performed on this visit for low back pain. Current request is for 30 Tablets of Flexeril with 3 Refills between 3/28/2016 and
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.
PCN-531 Smith Family Case Study I. Demographic Information The patient name is John Smith, 42-years-old white male who is currently working as insurance salesman. He has not been in any trouble at his job, but the nature of his job is quite stressful. He has been married for 17 years with two children (son of 15 years old and daughter of 12 years old).
Robbie and the team reviewed his HRST. According to the HRST, Robbie's medical diagnosis are exostosis of the medial malleolus, hypothyroidism, benign hand tremors, allergies and hypercholesteren. Robbie is under physician care for all diagnosis. He is currently prescribed four medications.
Issues She has Type II diabetes. Due to her compromised immune system, it is more likely that her injuries will take her longer to heal. Daily stressors and financial responsibilities may cause health concerns to take second priority. As a result, health issues
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
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
Medical records (2015-2016) indicated that the claimant had a history of thyroid disease, obesity (360 pounds), benign hypertension, and severe sleep apnea. His medical issues, including sleep apnea were under control; he was fitted for a new prosthetic arm. He reported that was working 15-18 hours a day. Per mental health records (2015-2016), the claimant reported that he was doing well, was taking his psychotropic medications with positive result and no adverse side effects. He denied symptoms of depression, suicidal ideation, or others, with the exception of anxiety that he controlled with medication.
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,