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…
The claimant has a past medical history significant for a fibromyalgia, cardiomyopathy, migraines, osteoarthritis, endometriosis, recurrent MRSA, and severe exhaustion. A progress note from Henry Echiverri, MD, dated 06/07/2017, indicated that the claimant presented with a possible diagnosis of multiple sclerosis. She stated that bumping into walls had been on for years, but had worsened the past few months. She felt that her vision was off and the pupils just dilate without a cause.…
The resident skin upper and lower limbs are pink, warm, and dry with a soft texture. Her skin turgor is less than 2 seconds with no wounds or lesions noted. There are pressure ulcers located on left and right buttocks. Resident scored a 13 which means she is at high risk for pressure ulcers on the Braden scale. The resident’s hair is straight, gray, fine with no appearance of balding.…
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.…
Anne is a 44-year-old White Female who presents to CRU from St. Luke's ED. She is currently homeless and was in prison 3 years for assault with a deadly weapon. She reported been diagnosed with PTSD and bipolar. She has an AA in communication, and unemployed. She reports relapsing on meth 2 weeks ago.…
This is 38 year old white male. he is here complaining of lestless legs syndrome. Patient reports it's been going on for several yeras, but now it is getting worse. Patient is acurrent smokerwith 20 pack year history. Patient denies use of alcohol or illicit drug use.…
Mrs. Smith is a 55 year old female who presented to the ED via LEO with acute psychosis. She was found in the street by LEO trying to jump in front of on-coming traffic. At the time of the assessment Mrs. Smith presents calm with rambling speech. She states the police are killing me, I'll try to go head and die for you. She denies suicidal ideation, homicidal ideation, and symptoms of psychosis.…
SUBJECTIVE The offender is in clinic today to follow up on her fibromyalgia and bilateral knee pain. She is actually leaving the facility in a few days. She says she is doing well with her pain management. The Cymbalta is helping and she is using the Mobic. She plans to follow up with her orthopedist after she leaves and is thinking about having her left knee replaced where she has already had a cartilage implant.…
The patient is a 48 year old male who presented to the hospital with suicidal ideations with a plan and homicidal ideations towards community members. The patient reports auditory hallucinations of his stepfather telling him to harm himself. The patient reports that he does not feel safe by himself. During the time of assessment the patient was awake, alert, and cooperative.…
CHIEF COMPLAINT Groin pain. SUBJECTIVE Mr. Yabsley is here for followup after he was seen in the clinic yesterday for groin pain. An ultrasound was ordered and is available for review today. Mr. Yabsley reports 9/10 pain located just behind the pubic bone which radiates up into his hip and lower left back.…
Patient reports she feels good and denies depressive moods, thoughts of suicide or homicide. Denies any…
DOI: 10/14/2009. The patient is a 44-year old female hospital medical records clerk who sustained a work-related injury after tripping over garbage can and fell on her right knee on 02/07/2010. Based on the medical report dated 08/19/16, the patient complains of 7/10 pain to her lower back, left knee, right knee and right ankle. The pain radiates to the left leg and right leg. Of note, she had surgery on the right knee to drain fluid in 2010, 2012, and 2014.…
On examination, the patient has normal strength and tone. No involuntary movements are noted. Her movements appear purposeful and normal, specifically there is no tremor or shaking and they are not slow. No fasciculations are noted. Tapping muscle tendons elicits a normal…
She currently rates her pelvic pain at an intensity of 4 to 6 on a scale of 10 on most days, and as a 10 of 10 during menses. Additionally, she became sexually active about 6 months ago and over the past 3 months has had severe pain with intercourse. The patient has…
The patient is a 24 year old male who presented to the ED via LEO under IVC until further evaluation, with suicidal thoughts with a plan to hang himself. Further, patient reports homicidal statements with a plan to several family members. The patient reports relational issues and family conflict as contributing stressors. The patient arrived with a BAC of .18. The patient denies suicidal ideations, homicidal ideations, and symptoms of psychosis.…