C4-5 Injury

I spoke with the family and arranged for him to have video call his son so that he can see and talk to his granddaughter. This helped the patient’s willingness to participate in activities of daily living and reenergized him.

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

PAST MEDICAL/SURGICAL HISTORY: As above. SOCIAL HISTORY: Status post heavy smoking, 50+-pack-year history. He quit 10 years ago. Status post alcohol abuse, quit 3 or 4 years ago. He lives by himself and no longer drives but has 2 daughters here in Miami who take him where he needs to go. FAMILY HISTORY: Patient’s wife died 14 years ago of COPD due to lifelong smoking. Brother has diabetes mellitus. Unremarkable family history otherwise. REVIEW OF SYSTEMS: No fever, no nausea, no vomiting. Patient has incontinence of bowel. No shortness of breath, no chest pain, no palpitations. PHYSICAL EXAMINATION: Well-developed, well-nourished white male who is alert and oriented x3. Wears bilateral hearing aids. Afebrile with blood pressure 130/70. NECK: No carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: S1, S2 normal. No murmur. No S3 or S4. ABDOMEN: Soft, nontender. No arterial bruits. No masses, no organomegaly. EXTREMITIES: No edema. No pulses present in the lower extremities. The right great toe is absent. The left great toe shows a 2 x 1 cm deep ulcer with redness around the toe with pus extruding. PLAN 1. Get consult with Dr. Beth Brian, Infectious Disease. 2. Follow up with Dr. Hirsch, Orthopedics. (Continued)

PHYSICAL EXAMINATION: HEENT: Tympanic membranes and external auditory canals are within normal limits. Throat is clear with no gingival lesions. He is ______________. No obvious proliferate retinopoathy. NECK: No carotid bruit. No thyroid enlargement. LUNGS: Clear to auscultation. HEART: No S3, S4 or murmurs. ABDOMEN: Soft with no organomegaly. Normal bowel sounds. FEET: Good dorsalis and posterior tibial pulses bilaterally. Left foot has no abrasions, lesions, sores or ulcers. Right foot shows obvious deformity from previous break. He has an area located between his second and third metatarsal head that has clearly been an abscess that has broken through. He also has an obvious foot ulcer located over the instep of his right foot, full thickness. There is tracking to the broken foot, to which the ulcer area is connected and there is a question of osteomyelitis in this area.

CP is a retired, 89-year-old male of upper-middle socioeconomic status. CP earned a degree in law to become an attorney. Prior to retirement he had 35 years of experience and his own practice. He had a right posterior hip replacement following a fall that fractured the right femoral neck. The fall occurred when he was walking from his home to the end of the driveway to throw away linens. Part of the linens slipped out from underneath the pile he was carrying, he stepped on it, fell and rolled down the driveway. He was taken to the hospital where he was to have a right hip replacement. The surgery went well, but he had to receive a blood transfusion. He has been transferred from the hospital and is currently at an inpatient rehabilitation center.

shortness of breath. Pain improved with sublingual Nitroglycerine and Aspirin given by EMS. On arrival to ED his blood pressure was 154/94, HR 70 bpm, RR 19 and SpO2 98% in room air. Heart, lung, abdominal and neurological examinations were unremarkable.

He has full paralysis of lower extremities and trunk. Travis is currently using a wheelchair and learning to take care of himself. He is learning to use assistive devices for ADLs with the help of occupational therapy and physical therapy. He tolerates a regular diet well and drinks 1500-2000 mL per day. He is on a bowel-retaining program and takes Colace 100 mg by mouth twice a day to prevent fecal impaction. Although Emma seemed overwhelmed at times because of Travis’ condition, she is very supportive and asks staff several questions to become more familiar with her husband’s current condition. Also, the nursing staff at the rehabilitation facility is training Emma on bladder emptying and intermittent catheterization.

Chweyah, dated 08/11/2017, indicated that the claimant presented for a follow-up visit after his discharge from the hospital on 08/08/2017. He was admitted on 08/04/2017 due to normocytic anemia, pain in both knees, starvation ketoacidosis, hypertension, gout with tophus, and duodenitis. The esophagogastroduodenoscopy revealed erythematous duodenopathy, erythematous mucosa in the antrum, and small hiatal hernia. He had a colonoscopy which revealed internal hemorrhoids. Objective findings showed blood pressure of 112/86 with a pulse of 105. He was diagnosed with quadriceps weakness, pain in both knees, normocytic anemia, type 2 diabetes mellitus, hypertension, stable chronic kidney disease stage III, and bilateral impacted cerumen. It was noted that he can return to work on 08/16/2017 with limitations of not standing for more than 10 minutes at a time for 1

On 1/16/17 I met Mr. Anderson at the office of Dr. Rampersaud. Mr. Anderson drove to the appointment. He uses 2 canes to walk. He reports that he and his wife drove to Florida on 1/4/17 to 1/15/17. He said they walked everyday while he was there. He reports his pain is a 9. The pain is in the left Si and caudal along with the low back. Mr. Anderson is scheduled for several injections today after we meet with Dr. Rampersaud. Mr. Anderson’s current medications were discussed. I remind Dr. Rampersaud that we are on a tapering process with the medications. Mr. Anderson was instructed to decrease the Dilaudid to 3 times per day from 4; the

The patient, Jane Doe (pseudonym to protect patient’s privacy under HIPAA), was admitted to the hospital on May 1st for bilateral lower extremity pain. She was diagnosed with lower extremity cellulitis, a bacterial skin infection. Though the infection was in her legs and she reported pain, she could ambulate with her cane. Her background showed that she has a history of hypertension, peripheral vascular disease that led to chronic venous stasis ulcer, and obesity. She had no known drug allergies, and was full code (full resuscitation). Her progression of hospitalization showed that she had increased swelling in leg, could not tolerate ultrasound to her legs, started on vancomycin (antibiotic), and was scheduled for biopsy on her right leg. She

Member experienced moderate pain due Dx. Osteoarthritis, have an unsteady gait, experiences dizziness (new medication Flomax 0.4 milligram) and is a risk of falling (score 11). He needs assistance of daily living. Goes to bathroom frequently due to Enlarged prostate.

At today's visit he is awake, alert and oriented. He complains of generalized pain. He states “I have pain all over today, my head, my back, my feet" I have not felt good for the last few days”. He rates his pain as 6/10 in severity; he describes his pain as shooting pain in different places. His pain does

At today's visit he is accompanied by his son in law and daughter. He reports pain in his hands and fingers that is a result of his RA. The pain starts in his fingers and radiates up his arms. He also complain of pain in his back that he contributes to his history of herniated discs. The severity of his pain is a 2/10. He decribe the pain as a shooting pain that is worst at night and when he relaxes. He states that since starting oxycodone IR 5 mg every 8 hours as needed, his pain is much better. He takes an average 1-2 prn dose daily. He feel that this regimen is effective in palliating his pain. He complain of neuropathic pain in legs, he have numbness and tingling in both lower legs. He uses Voltarin Cream BID and take Gabapentin 400mg

It is important to take a history of the patient. How long has he been having problems

James was a farmer, active every day of his life from a very early age. As a child, he helped out with the farm chores and the older her became, was more active in the daily grind of running a farm. His schedule was up before dawn and to bed by 10pm. Over the years of constant movement of his joints, James required a hip repair as the cartilage was nearly destroyed. He was 76 at the time of this first surgery and this is the identified beginning of his progressive aging. James identified himself as the provider in the family and the surgery and ensuing rehab took a hit on his ability to perform at his previous ability. Following his initial surgery, her found himself requiring surgery on the other hip and his lower back. James is seen in the clinic for follow up for evaluation of chronic pain and his functionality in everyday life. He is withdrawn and quiet; answers questions only when asked numerous times. His wife is with him and states he sleeps often throughout the day, moves about very little, and only watches TV. He