A review of her medical records indicates that she has chronic lower back pain that is uncontrolled. She has a history of spinal fusion and was been followed by Dr. Corner. She was living at home, but recent transferred to the ALF due to her multiple falls at home. She requires taxing effort due to her falls and increased muscle weakness and unsteady gait. She is having difficult getting to her appointments with Dr. Corner. She suffers from co-morbidities of HTN which is stable, COPD which is chronic and poorly manage-she is a smoker and is not ready to quit. As a result of her COPD she has exertion SOB for which she use a inhaler. She also suffers from DM which is managed with levemir and metformin and GERD which is stable.
At todays visit
At todays visit