Ht: 62”, Weight: 134 pounds, BMI: 24.5 Temp 98.4 BP 128/90 P 76 R18, even. The Oxygen saturation 98%.
Dr. Justin Clayton at the Mercy Clinic Orthopedic Surgery evaluated the claimant on April 6, 2018. Dr. Clayton stated the claimant may have rheumatoid disease and prescribe him Meloxicam. In addition, he reported the claimant would be referred for further arthritis evaluation (Ex. 23F).
Patient S.G. is a 67-year-old female who came to Lutheran on March 28th. This patient’s pennant history has to do with the reason for her admission of a red swollen left leg. This patient has a fibromyalgia, had ovarian cancer 15-20 years ago, Arthritis, chronic back pain, psoriasis, MRSA infection in 11/5/2014, Uterine cancer, Type 2 diabetes, and peripheral neuropathy.
One of his sons, Wayne is with him for the interview today. Mr. Ta complained about having bilateral ankle sweating for a year. He has no orthopnea or paroxysmal nocturnal dyspnea. He uses only one pillow to sleep. There is no shortness of breath on exertion. He does exercise regularly. There are no recent falls. He had fallen about 2 years ago when he tripped on stairs. He sprained his leg, but was fortunately without any fractures or serious injury. He was previously on propranolol, but that has been changed to bisoprolol. He denied having any liver or renal problem.
The patient is a 66-year -old retired black male. The purpose of the visit was to determine medication compliance, evaluate functional and mental status and perform a complete physical evaluation. His chief complaint is left knee and foot and calf soreness and ankle swelling without any injury for approximately seven days. He states that he has pain in his left knee, soreness to his calf increases with swelling and redness to his left ankle but no temperature changes to his left leg or foot. He states that his calf pain increases with dorsiflexion of his left foot. He describes the pain in his knee as pressure and rates the pain as 4/10. The pain does not radiate to anywhere other than his calf and knee.
O: On inspection, no edema or discoloration noted (patient was on ice for 10 minutes already at that time) Full ROM, reports severe pain (10/10) with overhead reach; Increased pain with Hawkins' Impingement
Weight 291, pulse 82, respirations 18, temp 98.1, blood pressure 162/96, O2 sat 96% on room air. Alert male, in no acute distress. Pleasant and cooperative. Skin is warm, pink, and dry. Speech is clear. Answers questions