On 11/15/2016, the claimant reported a return of symptoms and stated that she started having spasm while working. On 11/18/2016, the claimant complained of right sacroiliac joint pain and sacrum pain that was described as moderate and constant which was rated as 5/10. There was also mild-moderate and constant right hip pain that was rated as 4/10 as well as moderate and constant neck pain that was rated as 6/10. The neck pain was unchanged since the last visit while the pain in the right sacroiliac joint, sacrum, and right hip were getting better. Examination revealed that there was increased myospasms in the right paralumbar, right parathoracic, and right paracervical muscles.…
I just wanted to drop you a short note on your patient [Name]. As I know you are well aware, she was seen by my partner, Dr. [Name] for evaluation for bile duct stones, and found to have very large load of stones in the left intrahepatic ducts. She returned to seen me on July 16, for repeat ERCP, at which time with the plan to use SPYGLASS cholangioscopy technology to try to manage these stones. We had provisionally also scheduled her for a PTC tomorrow if our efforts failed. We perform her ERCP under MAC anesthesia.…
32 Y/O African-American male, presents with c/o frequent urination and burning during urination x two days. He is going to the bathroom more than normal (3-5x normal but went up to 8-9x per day). He has not been able to produce urine every time, burning during urination. Lower abdominal Pain (6/10) started from yesterday. Denies unprotected sex.…
Case Report: This is a 56-year-old white female with a history of cirrhosis secondary to alcoholism and NASH, history of portal hypertension and ascites, and hepatic encephalopathy, who was brought to the ED by her mother and daughter due to concerns about confusion. The patient is confused and unable to answer questions; therefore this information has been obtained by family members. According to the family members, the patient has been confused for 2-3 days and has had a few episodes of emesis for the last few days and was drinking an excess amount of lactulose for the last 3 days due to constipation; however, she did have a loose bowel movement yesterday. The patient has been complaining of diffuse body pain including her abdomen, but she…
The patient is a 93-year-old lady who is brought to St. Joe's for primary care doctor's office. The patient evidently had a fall witnessed by her neighbor. The neighbor brought her to her primary doctor's office and then referred to the ED. Th patient has a history of some early dementia has difficulty answering questions but she denies pain anywhere. She is evidently on Plavix secondary to a past CVA.…
SUBJECTIVE He was seen for two issues. 1. He just came back from Oak Park Heights last Thursday after he had treatment with C. diff; however, he did have a C. diff in the stool that was done on 09/13/2017, and also a fecal lactoferrin and both of them are positive. At this time, he continues to have abdominal cramping and also loose stool about 2-3 times a day. 2.…
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.…
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.…
Diagnostic Reasoning Symptom Assignment Student Name: Kristy Anderson Symptoms: 55 year old male presents to your clinic with and upset stomach and belching past several months. A. Identify the appropriate history questions to be asked of your patient to discriminate critical characteristics about the above presented concern. 1. Can you identify when exactly the upset stomach started?…
During my time in clinicals on a pediatric floor, I have participated in the discharge of patients and their parents. Pain management and comfort were two of the few topics that parents expressed concern about after discharge teaching. While the nurse attempted to address these issues, it felt as though the parents left the hospital without full confidence in how to manage their child’s pain. It became clear that parents needed further, specific discharge education on pain management when their children were prescribed at-home analgesics.…
Annotated Bibliography Cagle, J. G., Zimmerman, S., Cohen, L. W., Porter, L. S., Hanson, L. C., & Reed, D. (2015). Empower: An intervention to address barriers to pain management in hospice. Journal of Pain and Symptom Management, 49(1), 1-12. doi: 10.1016/j.jpainsymman.2014.05.007.…
UNJUST PAIN MANAGEMENT For the African-American Community As nurse, we seek to aide all of those who seek our help. However, not everyone is treated justly when it comes to pain management and pain control. An example of this disparity would be the case Dominique Oliver, an African American male, received a compound fracture to his lower leg while attempting to steal a soccer ball from a player on the opposing team while playing sports in high school.…
Pathophysiology of Diverticular Disease Diverticular disease is a condition that most often affects the sigmoid colon and is characterized by a number of small pouches that extend to the surface of the colon. When all four layers of the colon are herniated, it is called a true diverticulum. Typically, diverticula are pseudodiverticula and involve only the mucosa and submucosa (Porth, 2011). The colon could have one diverticulum, or numerous diverticula.…
Primary diagnosis: Affective disorders. Secondary diagnosis: Chronic pain. Code 2480- but that code is “Diagnosis established – no predetermined list code of medical nature applicable. Did not find code for pain or chronic pain.…
Chronic pain defined as pain that lasts longer than six months. Chronic pain can be mild or excruciating, episodic or continuous, merely inconvenient or totally incapacitating. Due to the trouble of categorizing a patient with chronic pain, I would complete comprehensive health history assessment. This will provide subjective and objective data from the patient along with the examination of the patient.…