On examination, both knees were stable joints. The right did have more of an effusion
On examination, both knees were stable joints. The right did have more of an effusion
Pelvis is stable. The patient is ambulatory and show no restrictions in motion at the hip, knee, ankle, or foot. Examination of the left upper extremity shows a posterior splint. This is removed and shows some mild swelling and ecchymoses in and around the posterior aspect of the elbow and ulnar forearm. Axillary, radial, median, and ulnar nerves are intact to motor and sensory tone.…
She converses appropriately. She is in no acute distress. Blood pressure 120/82. Pulse is 66 and regular. Weight 192 pounds.…
After that, she went through ten weeks of not moving, then an eight month recovery with mobility scooters, surgical boots, and crutches. Lastly, the cartilage between the navicular and the top of her foot tore apart causing bones to rub against each other; over time the cracked bones fused…
A review of the records reveals the member to be an adult female with a birth date of 06/06/1956. The member has a diagnosis of rheumatoid arthritis. The member’s treating provider, Laura Summers, MD recommended the member continue her treatment of Remicade infusions 7 mg/kg every 6 weeks. The carrier has denied coverage of Remicade infusions 7 mg/kg every 6 weeks as not medically necessary.…
There is no tenderness to palpation. Examination of the right lower extremity shows the patient has tenderness to palpation along the lateral thigh, especially at the mid portion of the right trochanter. Ober 's test is not performed at this time given the patient 's posturing, but he shows gross clinical symptoms of inflamed bursa through the right trochanteric region. Knee motion is full and shows no limitations. The ankle is mildly swollen.…
Treatment plan includes therapy to the left knee twice a week for 4 weeks and a left knee patella tracking brace. Based on the primary treating physician’s progress report by Dr. Steinhardt dated 01/19/16, the patient complained of foot and ankle pain and stated that it was worse now than it was prior surgery. His left knee pain is stronger as well. Physical examination revealed reduced range of motion at the left ankle in all ranges by 50% or greater with weakness.…
At today’s visit, she is awake, alert and oriented. She reports chronic, dull, constant, sharp left hip pain. She rates her pain as 7/10. She states that the pain affects her mobility and makes it difficult to ambulate. She takes Percocet…
A review of her medical record indicates she suffers from late effect CVA with muscle weakness that occurred earlier this year. At which time she revoke hospice and was admitted to the hospital and treated for her CVA with rehab stay upon her discharge from the hospital. She suffers from chronic back pain/post herpetic back pain resulting for history of shingles. She suffers from co-morbidities of CKD-Chronic, Afib-stable and osteoarthritis that is chronic.. She also has a history of functional decline, weight loss, HF, TIA and Urinary incontinence.…
Per the panel QME Supplemental report dated 12/31/15, the patient is not yet at maximum medical improvement (MMI). Patient was diagnosed with right knee sprain with chondromalacia/osteoarthritis. As per medical report dated 8/24/16, patient complains constant bilateral knee pain, right greater than left, rated 8/10,…
Leslie Patton is a 74 year old retired musician. She lives on her own in an apartment in Harlem. She has no children and never married. Due to many years of playing the piano, she was diagnosed with Osteoarthritis about 10 years ago. As she continues to age, the joint pain and its effects have been worse.…
The patient is a 91-year-old female brought in from the nursing home after being found on the floor. She gives a history of hearing the phone ring, attempting to answer the phone and tripping over the phone wire. The history is somewhat confusing as the patient has been wheelchair bound nonambulatory for the past 6 years. Her medical history is significant for congestive failure, CVA with some residual left-sided weakness, hypertension, a DVT (presently on Coumadin), and some dementia. Significant findings are a hemoglobin of 12.2, which on admission dropped to 10.…
IS, a Caucasian female over the age of 90, with a history of atrial fibrillation, congestive heart failure, stroke, and age-related chronic obstructive pulmonary disease was admitted to the hospital with a fracture in the right hip, a concussion, and possibly a cerebral hemorrhage. The injuries were sustained by IS after hitting her head on an outside low-lying branch that caused her to fall. As a result, IS was taken from her home by emergency medical services to the emergency room of a local hospital. After evaluation in the emergency department, IS was moved to a private room and remained there for five days, followed by ten days in a rehabilitation facility.…
Introduction Perfusion is a very important aspect to the human body. Perfusion is defined as the flow of blood through arteries and capillaries that deliver oxygen and nutrients to the cells and removing cellular waste from the body (Giddens, 2013, p. 148). For us to maintain optimal perfusion, we need are heart to generate sufficient cardiac output. This means transporting the blood through patent blood vessels to supply the tissues throughout the body. Impaired perfusion may occur when the blood supply is reduced or completely interrupted (Giddens, 2013, p. 148).…
Looking at her medication list, her medical history may be rheumatoid arthritis, osteoarthritis, GERD, hypertension, anemia, hypothyroid, and a current infection. Why should you query her on the Bactrim, and would you consider it a routine home medication? Explain your answer. I would question the need for her to be on TMP/SMZ since she has no current infection that she is aware of. Although, she may be on this medication to regulate and prevent endocarditis since she has a history of hypertension.…
The patient is a 92-year-old female with a history of several falls several weeks ago. She was initially seen in Hackensack in the ED where allegedly there were no fractures found and she was sent home. However the patient patient is languished at home, increasing pain, inability to walk resulting in further falling and worsening of her symptoms including anorexia, constipation. She was seen initially St. Joe's ER on 12/18/2016 and workup was done and patient was placed at the discretion of Dr. Porter in observation status.…