Lifewell South Mountain is his outpatient treatment agency. He is alert and oriented 4x. He presents as calm, appropriate and cooperative during the intake process. Patient denies DTO/DTS. He denies AH and VH, but stated he was hearing voices yesterday.…
Glomerulonephritis is the inflammation of the tiny small blood vessels within the kidneys that acts as filter called glomeruli. The disease damages the kidneys' ability to remove waste and excess fluids from the body. Glomerulonephritis can be acute - sudden attack of inflammation, or chronic- long-term and coming on gradually. In the past, chronic glomerulonephritis was the common cause of chronic renal failure but as of today, diabetes mellitus and hypertension are the main causes of ESRD, which account for almost 60% of dialysis patients. The cost of treating a kidney disease is uneconomical1.…
SUBJECTIVE Mr. Keith is a 45-year-old inmate from Stillwater who was referred by Dr. Quiram for evaluation of fibromyalgia. Mr. Keith has a long history of multiple medical problems, including hypertension, diabetes, hyperlipidemia, gastroesophageal reflux disease, and degenerative disk disease. His history dates back he says to age 12, when he first received the diagnosis of fibromyalgia. This was apparently in the early 90s, by 1998 he had developed diabetes mellitus and by the year 2000 he had a diagnosis of diabetic neuropathy.…
Jessica is a 21yo, G1 P0, who was seen for an ultrasound evaluation and consultation for FTS. The patient has a history of opiate use disorder involving heroin addiction. She has used this off/on with the father of the baby and has actually used it recently. She states that she recently entered your Subutex program and is now on 8 mg Subutex b.i.d. and believes that she is doing better.…
A progress note from Dr. John Gleason (Family Medicine), dated 06/11/2017, indicated that the claimant had been unable to work as she had been very fatigued and had a lot of pain and issues. She reported having a weakness, a burning sensation in at her back, and a poor balance with dilated eyes all the time. She also had a burning sensation in her legs and stated that she was unable to achieve orgasm for many years. Her BMI…
300.82 Somatic Symptom Disorder with Predominant Pain and Persistent – Severe V61.03 Disruption of family by separation or divorce V61.10 Relationship distress with spouse or intimate partner V62.29 Other problem related to employment Justification of 300.82 - Somatic Symptom Disorder with Predominant Pain and Persistent – Severe Matt has more than one somatic symtom present that is causing him distress and significant disrution in his daily life. Matt has overal pain, specifcilly absominal pain, and has aches, feels sore, and tired (Criterion A). Matt has not been able to work for 2 years now due to the increase in pain.…
Database and Assessment Table 1 – Physical Nursing Assessment Data GENERAL: Patient is an 88 year-old Caucasian male. Vital signs stable at 97.3°F, 82BPM, 22 breaths/min, 84/54mmHg, 100% on 1.5lL O2, 0/10 pain, patient weight 58kg. SKIN/HAIR/NAILS: Skin was thin and fragile, warm and moist, skin color slightly pale, skin tear on left upper arm measuring 3 inches, no bleeding or pain.…
Group I, Category 19 Incorrect RFC Decision ISSUE The DDS proposed a medical vocational allowance determination. The evidence in file does not support the severity as assessed by the DDS. CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES) This 45-year-old claimant is filing a DIB claim alleging disability due Ehlers-Danlos Syndrome, fibromyalgia, Raynaud's Syndrome, chronic regional pain syndrome, chronic migraines, madelung's deformity, PTSD; panic, anxiety disorder, vertigo, and tendonitis of the left ankle as of 08/26/2014.…
When confronted about admitting being suicidal and taking medication to this clinician, patient stated "I just thought I might get to go to back to Highpoint if I said that, they have some good information up there." The patient presents with minimal eye contact during the assessment and story has change a few time. The patient reports he does not have a place to go. Patient reports having a history of suicide ideation, the last one being in 2015, where he was placed at HPR, when he reports cutting himself and a history of bipolar. The patient currently has multiple laceration on both arms.…
At today’s visit he is accompanied by his wife, he is awake, alert and oriented. He reports dull, left flank pain, severity 4/10, cancer related, manage with Percocet 10/325 mg. He states that he was talking morphine Er 30 mg, but has stopped the morphine because his pain improved.…
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.…
Cushing’s Syndrome Case Study, Manifestations, and Nursing Implications Introduction A 44-year-old male presents with complaints of body malaise and anorexia. He has noticed his attitude going from happy to depressed. He complains of weight gain, bruising easily, and frequent backaches. His arms and legs are thin.…
Phantom Limb Pain (PLP) is described as a sense of pain in a non-existent extremity. This means that one who is missing their limb may feel pain which is perceived to be originating from where the original arm was. Not all cases of PLP are the same because everyone processes limb loss differently and no single injury are the same. Phantom limb pain can occur in various parts of the body and is not limited to a particular type of treatment. Similar to other illnesses, sensation vary from case to case and may depend on the degree of trauma.…
Ms. Iversen is dependent on some dressing, bathing, hair washing, meal preparation, house cleaning. She is non weight bearing to the right leg. MEDICAL/SURGICAL HISTORY Ms. Iversen said she has ha history of cervical pain. She has a congenital fusion of the cervical spine. Ms. Iversen denied any smoking, alcohol use or drug use.…
This case study follows the management of a 47 year old man who attends a Podiatry clinic presenting with pain and a fusiform swelling on the posterior aspect of the right ankle. The patient states that he has experienced discomfort for approximately the last three months, with the pain exacerbating after exercise. He discloses that he recently joined a local running club with the aim of training to run a marathon next year, leading to a significant increase in his activity levels. The patient is concerned as pain levels have increased dramatically as of late, causing him to miss the last few training sessions. At worst, he states that the pain scores an 9/10 on the Numeric Pain Rating Scale.…