Subjective Data: Chief Complaint: Right ankle pain for two days, routine visit for osteoarthritis, hypertension, gout, and diabetes mellitus (DM) evaluation. History of present illness: Mrs. V. J. a 68 year-old-African American female presented in the clinic complaining of a burning pain, stiffness, swelling right ankle, which radiates to the right metatarsophalangeal joint for two days, pain scale seven out of ten. She denied falling or hitting her right ankle against an object, just woke up around three that morning to use the bathroom and could barely walk. She also stated that right ankle edema has increased more in the past two days due to cold weather. She takes Norco 10/325mg two tablets orally every six hours and apply warm …show more content…
She had three siblings, one sister and twin brothers, sister is 60 years old, newly diagnosed with DM and twin brothers are 58 years old alive and well. Review of System (ROS) General: Neat Skin: Reports swelling right ankle and right big toe pain. Eyes: She wears reading glasses Ears: Denies ringing in the ear, pain, discharge, or hearing impairment. Nose: Denies nasal discharge, Congestion, or problems with smell. Throat: Denies problems with her gum and mouth. Swallows without any difficulty. Neck: Denies any edema or bruises around the neck. Respiration: Denies labored breathing. Cardiovascular: Denies chest pain, bilateral ankle edema, but severely increased on the right with burning pain. Gastrointestinal: Denies anorexia, nausea and vomiting, heartburn, abdominal pain, or constipation. Endocrine: History of Type two DM Objective Data: Vital signs: Temperature 98.7 Fahrenheit, Blood pressure 128/82, Respiration 16, weight194, height 5feet 8 inches, body mass index (BMI) 28. Generalized appearance well-kept wore a decent outfit, overweight, ambulates with a walker. Skin: Warm to touch, dry and intact Head: Normocephalic, atraumatic. Ear: No discharge or cerumen noted bilaterally, tympanic membrane normal without redness or edema. Nose: Nares patent without any obstruction. No frontal or maxillary tenderness during palpation of the sinus cavities. Pharynx: Oral mucosa moist, no dental cavities or plague
Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.
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).
01/14/16 Progress Report noted that the patient has severe and constant pain. It is associated with numbness, tenderness, and restricted motion. Current pain level is 8/10. The patient is here for injection to the left subtalar joint. The exam of the left ankle revealed intact skin. There was no erythema or abrasion. No signs of infection. NVI distally. Distal sensation intact and brisk capillary refill. Clinical Assessment: The patient would like to go ahead with the
12/24/15 Progress Report describes that the patient has right knee pain. The pain is frequent. It is aching and burning in quality. The current pain level is 0/10 and worst pain is 4/10. Bending, squatting, walking, weight bearing, changing clothes and ROM aggravate the pain. Rest, ice,
DOI: 2/3/2014. Patient is a 20-year-old male cashier who sustained injury to his right ankle when he slipped and fell. Per OMNI, he was diagnosed with right ankle sprain.
Based on the progress report dated 02/29/16 by Dr. Naraghi, the patient reports worsening of her right lower extremity with pain, numbness and weakness.
Ht: 62”, Weight: 134 pounds, BMI: 24.5 Temp 98.4 BP 128/90 P 76 R18, even. The Oxygen saturation 98%.
Vital signs: Blood pressure 128/79, pulse 77 regular, temp 98.2 Fahrenheit, O2 saturation 100% on room air. General: Well-developed, well-nourished,
She died March 31, 1995. She was also the youngest in her family. I am mainly
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.
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.
Vital signs: Blood Ppressure: 120/78 mmHg, Hheart Rrate: 92 beats/min, Rrespirations: rate 15 breaths/min, O2 Soxygen saturation: 97% on room air
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
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.
Annie is a 44years old female, presented to Emergency department (ED) complaining of terrible pain in her right big toe and has been exacerbated since last