Late Entry On 5/24/2016, CM met with the client and completed Bi-Weekly ILP Review. In the meeting client was dressed appropriately for the weather. Client appears to be cooperative, friendly and forthcoming with all information. SOCIAL SUPPORT UPDATE:…
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…
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.…
DOI: 12/23/2013. Patient is a 51-year-old female registered nurse who sustained a work related injury due to repetitive work. Per OMNI, she is initially diagnosed with strain to the knee patella. MRI of the right knee dated 10/9/15 revealed globular increased signal intensity is seen throughout the medial meniscus most consistent with intrasubstance degeneration; tricompartmental osteoarthritic changes; joint effusion; pre-patellar soft tissue edema, query contusion; and chrondromalacia patellae.…
Per the medical report dated 05/17/16 revealed that the patient has continued progressive weakness and numbness/tingling sensations into the bilateral wrists/hands radiating to the upper extremity, right greater than left. She reports having these symptoms…
Review of the medical record indicates that she was recently admitted to MHS for complaints of increasing fatigue, lethargy and leakage from her indwelling foley catheter. She had a urology consulted with Dr. Beltran for evaluation of chronic indwelling urinary catheter and persistent leakage with recurrent UTI. Review of her medical history indicates multiple sclerosis, UTI, Memory loss, Pressure ulcer, facial neuralgia, blood transfusion, chronic kidney disease, decubitus ulcer of back, GERD (gastroesophageal reflux disease), hypertension and legally blind. At today’s visit she is accompanied by her husband.…
SUMMARY OF CASE STUDY Bill, a 34 year old male, arrived at the doctor’s office experiencing pain in his right hip. Prior to this, Bill maintains an overall healthy lifestyle which includes exercising and activities such as; swimming, water skiing and scuba diving. Bill reports he has had no trauma to his hip. On this visit an analgesic and muscle relaxant were both prescribed to the patient and he was sent home.…
Jenny presents with sudden hip pain that developed 3 weeks ago which first occurred after she came home from work one night and has been persisting since. She describes her pain as ”dull pain” and rates her intensity of pain as 4 out of 10. The pain is located around her gluteus medius with no radiation down her legs, and no other associated numbness or tingling sensation. Her pain has not prevented her from working and she is still working and has not taken any days off work in the past year. She says the pain is typically aggravated by long periods of standing at work even though she makes an effort to stretch her hip muscles at work for some relief of the pain.…
51 year old African American male is here for toothache, has dental appointment in 2 days at BHC dental clinic. Patient is still on antibiotic for his URI form previouse visit. Patient reports much improved in his URI symtoms, but still coughing. Patient reports back pain as well. Patient denies wight loss, night sweet, chest pain, N/V/D. Patient denies depressive moods or thoughts of suicide or homicide thoughts.…
Bowel sounds were active in all four quadrants and non-tender. She had plus two pedal edema in both feet and is wearing compression socks to help with the swelling. My patient is waiting for doctor to release her to a special care facility where she will have to have help getting taken care…
CC: “I feel awful and ache all over” HPI: M.M. is a 19 year old female presenting to the clinic today with complaints of malaise, increased somnolence/fatigue, non-productive cough, fever/chills, headache, and generalized myalgia (7/10). Symptoms began yesterday morning, prior to school, and continued to get worse. Patient drank an energy drink around 7pm yesterday and again this morning to increase her energy but was unsuccessful. She took OTC Tylenol last night for other symptoms with no relief. She has been unable to eat because of sore throat and sitting upright makes symptoms worse.…
Tramadol addiction is a condition that often takes many people by surprise: it rarely makes the news and is rarely associated with drug culture. Unfortunately, tramadol addiction is a reality. While it does offer a relatively safe pain control method to many people when used properly, its addictive nature needs to be better understood by people who either currently taking or are interested in taking it. Addictiveness Varies…
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…
Morphine is an opioid where as Tramadol is not an opioid but still binds into the opioid receptor and produces the same effect as an opioid would, if medication is strengthened. Both tramadol (oral) and morphine (oral) are commonly used for pain management. While tramadol is used to treat moderate pain, morphine is used for moderate to severe nociceptive pain, such as pain due to surgery, trauma or cancer. Evidence suggests that tramadol can ease opioid withdrawal, therefore it cannot be abused and may be beneficial for treating opioid dependence. Analgesic effects of tramadol are facilitated with a combination of mu-opiod agonist effects and norepinephrine and serotonin reuptake inhibition.…
Pain has only been seriously considered as a diagnostic tool since the 1990s, when pain assessment scales were popularized as a “5th vital sign.” In the same decade, opioid painkillers, such as OxyContin, began to be marketed as a non-addictive alternative to heavy narcotics. The change in this approach toward understanding pain in medical practice, coupled with the rescheduling of prescription opioids, led Americans to a more comfortable relationship with pain medications. Two decades later, however, opioid related overdoses have soared. Their questionable medical efficacy and addictive potential make these drugs, and the casual nature with which they have been prescribed, a threat to patient and public health.…