Case Study 27 Year Old AAF

HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weighed approximately 40 pounds. Around the first of January this year she began to complain of back pain that

Williams, the patient reports occasional low back pain that he rates from 0-3/10. On this visit, he has no low back pain.

Ashante has no known medical condition but she has complained that her chest is hurting on a frequent basis. She was recently seen at Florida Hospital and was prescribed ibuprofen for her chest pain, they indicated it is a muscle inflammation. Ashante has no mental health

The claimant has a past medical history significant for fibromyalgia, fatigue, arthritis, chronic pain, joint pain, leg pain, frequent urination, and swelling.

As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his

MEDICAL UPDATE: Client continues to report arthritis in her left leg and hand, high blood pressure. She also reports she will need surgery but she is waiting to be housed.

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.

Claimant reports history of multiple medical complaints. Since the age of 60 she reports struggling with urinary incontinence, which impacts her functioning at work. She reports feeling ashamed and guilty that she is unable to control her urination and has the need to periodically utilize the restroom or go to her car taking time away from her responsibilities. In the past few years claimant has severe intensification of physical symptoms, including back pain, right shoulder and hand weakness, blood pressure, headaches, sleep difficulty, and depression-related fluctuating appetite, fatigue and sluggishness. She reports experiencing heart palpitations present (racing heart), dizziness, and fear of actual fainting, a feeling of choking and not being able to breathe, chest pains, nausea or intestinal pains, shortness of breath, tremors in the hands, hot flashes and tunnel vision. The claimant reports that she sleeps very minimally; averaging 3-4 hours of sleep per night on an interrupted basis due to physical and emotional pain. She reports that she has very poor mobility due to pain and depression-related poor motivation.

This is 35 year old WM. Patient was seen at UAB ED for UTI and kidney stone on 3/30/2016. Patient was discharged with roboxin and ibuprofen. Patient has a history of Hep C, was told about 12 years ago, and was retested at UAB and HVC was positive. Patient is a current resident at the Villige. Patient has a history of substance abuse, denies current use, last use about 10 days ago. Patient is a current tobacco user, denies use of alcohol or illicit drugs. Patient reports some depressive moods, denies thoughts of suicide or

This 54 year ld AAM. Patient has a history o fDM, HTN, and hyperlipidemia. Patient's current medications are Glipizide 10 mg BID, ASA 81 mg QD, Triamtereine /HCTZ 75/50 mg, Pravastatin 40 mg QHS, and lorsatan 300 mg QD. Patient states he is taking all mthe medications as prescribed, and he thought he was doing fine. Patient states no one in the Federal Prison System had checked his A1C in several years. The patient's A1C today is greather than 14 %. Patient denies buller vision, headache, chest pain, SOB, N/V/D, or fever. The patient denies decreased sensation of his feet, increased thirst or urination. Patient denies any depressive moods. The patient is here with his wife and had a long disussion with the plan of care for his DM, HTN, and

The patient was last seen in the office in February. Please see that note for complete details. She has several issues she would like to discuss today. She tells me that she has really been under a lot of stress of late. She had been caring for her sister, who has uterine cancer. In addition, her husband 's brother recently died, and there have been issues regarding a property they co-owned. She sold her house in New York and is now renting a house here in Portsmouth. She feels all that she has been doing is moving and cleaning. She feels that she is a little bit settled, however and is hoping that she can get back to her normal regimen. She has not been walking as much as typical, and she would like to lose a couple of pounds and plans to get back into that, as well as her physical therapy exercises that she has been doing for her neuropathy.

Telephone contact made to the patient. Two patient verifier used to confirm name and DOB. Patient states that she continue to have severe lower back pain that worsen with movement and standing for greater than 30 mins. Currently, patient rates her pain 5/10 resting, with an occasional pinching feeling in the lower back. Patient states that she is very concern because she needs her husband help for almost everything such has help with ADL, household chores. Patient states that her husband is due to deploy in January 9. Patient states she is schedule for her MRI January 5. Patient is requesting that her MRI be done asap. Patient states that she is taking her medications as prescribed but she continue to be in pain. Acute Apt was schedule for

This is 36 year old AAF. Patient reprots she has a history of seizure disorder, and currently taking carbamaaazepin 200 mg QID. Patient has NC Medicaid. Disusse with the patient to talk with ARMS Medicaid/Medicare Specialist. Patient was told to return to the clinic in 2 months for carbamazepine level. Also patient is to sign the consent for medical records from NC PCP. Patient reports generalized weekness and tireness, requestign elevator pass at her group home. Patient denies chest pain, SOB, n/V/D,or

An assessment was conducted in the clients home, patient felt it would give us more privacy and her husband was not at home. Patient lives at home have always had a healthy relationship with her husband almost 55 years. Retired registered nurse who maintains all her faculties. FB is a 78-year-old female who has a history of hypertension, the beginning stages of CHF, injured right hip and leg, and stress incontinence. FB visits her PMD annually to her annual examines. Monitors her blood pressure by exercising, preparing meals at home and watching sodium intake. Overall, patient lives a healthy lifestyle. Even though she has discomfort in right hip/leg and occasionally lower back pain,

This 33 year old AAF. Patient has history of DM and HTN. Patient states she was on inslin, but not for the past 2 weeks. Patient states she was on 70/30 15 units BID, and metformin 1000 mg BID, and her BS was still in upper 200's and lower 300's. She didn't wanted to go back to the Health Department, because she was miss treated and felt like her chronic conditions were not being managed with care.