A review of his medical record indicates a medical history of peripheral edema, chronic pain Seizures, Hypotension, Prostate cancer, bladder removal, sleep apnea, NIDDM, gout, kidney stones, neuropathy, pulmonary embolus-has filter, DVTin right leg, chronic edema in right leg and chronic pain syndrome.
At today’s visit he is accompanied by his wife. He is homebound due to his immobility. His wife reports that his immobility started 8 years ago. He has not left his room in the last 3 years due what he describes as a fused neck and coccyx pain that makes him unable to sit. The wife reports that the patient has prostates cancer 8 years ago for which he had surgery and radiation. A year after his radiation treatment he developed pain in his coccyx as a result of damage nerves form his radiation …show more content…
When he was admitted in February he had a thoracentesis and during his hospitalization in March he was treated for pneumonia. He complains of neck, back and coccyx pain. He describes the pain as a dull aching pain. The pain does not radiate. It is a 8/10 in severity. He is not bedbound and spend 98% of his time in bed laying on his back due to his debilitating pain. He states because of neck pain his neck is fused in place, he cannot turn his head. His coccyx pain prevents him from sitting. As a result he spends his days laying and he is confined to his home because he cannot get in his car. He is at risk for developing pressure ulcers. He is getting PT, SN, OT from kindred home health and VA approved HHA visit from the VNA. He reports that he use to go to pain management for his pain but when he became homebound he was unable to make it to his appointment and wean himself off his pain medications. He complains of neuropathy in legs which he describes as “burning sensation that feels like my legs are on fire, especially upper thigh, it drives me crazy”. The patient was taking Lyrica, which he discontinued, states it was causing his
At today’s visit he is accompanied by his wife. He is homebound due to his immobility. His wife reports that his immobility started 8 years ago. He has not left his room in the last 3 years due what he describes as a fused neck and coccyx pain that makes him unable to sit. The wife reports that the patient has prostates cancer 8 years ago for which he had surgery and radiation. A year after his radiation treatment he developed pain in his coccyx as a result of damage nerves form his radiation …show more content…
When he was admitted in February he had a thoracentesis and during his hospitalization in March he was treated for pneumonia. He complains of neck, back and coccyx pain. He describes the pain as a dull aching pain. The pain does not radiate. It is a 8/10 in severity. He is not bedbound and spend 98% of his time in bed laying on his back due to his debilitating pain. He states because of neck pain his neck is fused in place, he cannot turn his head. His coccyx pain prevents him from sitting. As a result he spends his days laying and he is confined to his home because he cannot get in his car. He is at risk for developing pressure ulcers. He is getting PT, SN, OT from kindred home health and VA approved HHA visit from the VNA. He reports that he use to go to pain management for his pain but when he became homebound he was unable to make it to his appointment and wean himself off his pain medications. He complains of neuropathy in legs which he describes as “burning sensation that feels like my legs are on fire, especially upper thigh, it drives me crazy”. The patient was taking Lyrica, which he discontinued, states it was causing his