Case Study 51 Year Old AAM

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.

He is total care with his ADLS, he is able to verbalized his needs but unable to perform them. He reports that he had a colostomy placed in 2011 and urostomy placed in 2014. His father provides hygiene care and changes for both his colostomy and urostomy bag. He has bilateral arm/hand contractures and he has gotten weaker. He is getting OT and PT from kindred home health. He uses a hospital bed with air mattress and his father changes his position every 3 hours. He reports pain in his legs and back that is constant, dull and aching. His pain is worse with movement and dressing change. His current pain level is 8/10 on a pain scale. His pain regimen consists of fentanyl 75 mcg patch every 72 hours and oxycodone 5 mg p.o every 6 hours as needed for breakthrough pain. He has been taking 2 prn doses daily because he did not want to run out of medication. He states that 2 prn dose is not effective in relieving his breakthrough pain. He previously was getting his medication from his PCP but since his condition has deteriorated his parent who are elderly is not able to get him to the

My patient is a 58-year-old female, who presents with controlled type II diabetes, hypertension, and possibly thyroid tumors that have been there for a few years. She is under the care of a physician for her diabetes and associated controlled hypertension. I recommended several times that she see her physician after feeling the tumors around her neck and thyroid. Her medical history also indicates that she had rheumatic fever twelve to thirteen years ago, has arthritis in her knees, and occasional headaches. She is 5”3 and weighs 216 pounds. Her blood pressure was 126/80, pulse was 88 BPM, respirations were 20, and her temperature was 98.2 Fahrenheit. She doesn’t smoke and I made sure that she had eaten lunch and wasn’t hungry. She is currently on 100 mg Metformin for her diabetes, 120 mg. Lisinopril for hypertension, 40 mg. of Lovastatin to lower cholesterol, 80 mg. of Aspirin to prevent cardiovascular disease, and daily insulin. Reviewing her medical HX, I was informed that she usually checks her blood glucose daily, but had recently run out of strips, so it had been a

Patient L.H. is a 69-year-old married Caucasian male that is a retired teacher that lives at home with his

The patient Matt is a 19-year-old Caucasian male that was admitted to the unit and being treated for lethargy, excessive thirst, recent unexpected weight loss, fever and frequent urination. Patient is uninsured, a college athlete (runs 3-5 miles a day on the cross country team), works 16 hours a week on the night shift, lives with five of males and says his diet consist of fast food, prepackaged meals and admits to having 3-4 beers, 3-4 day a week and has an allergy to penicillin (hives) and sulfa drugs. Patient was treated for a UTI once 3 months ago. The patient’s current vital signs are: temperature of 101.6F, heart rate of 99, respiratory rate of 22, blood pressure of 119/76, SaO2 99% on

Ms. Castellanos reports she suffers from arthritis, dizziness, and headaches due to a head injury, hypertension, and cataract (both eyes). Client reports she underwent cataract surgery 10/8/15 in the left eye and 10/25/15 in the right eye. Client continues to reports she is currently taking the following medications: Meclizine 25mg, Simvastatin 40 mg, Gabapentin 300mg, Oyster Shell Calcium tab 500-200mg, Omega-3 Ethyl Esters 1mg, Losartan-HCI 100-12.5mgG, Amitiza 24 mg, and Sertraline. Client continues to report she is seen by Dr. Molinas Alveris tel3 718-4264747 located at 9319 Roosevelt Ave Fl 1, Jackson Heights, NY 11372.

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 39 year old AAM. Patient is here with several complaints. Patient has no medical condition, or long term medications. Patient denies any other issues except as listed.

The patient is an 88-year-old gentleman who is brought to St. Joe's ER complaining of inability to walk. The patient 6 days ago began to having trouble walking with his walker. He reported left arm pain which radiated up his left arm. The patient had pain in the left foot. The patient was taken to St. Joseph's Hospital in Wayne. In the ER he was diagnosed with gout and begun on Colchicine. Since that time he has shown no improvement. He has become essentially chair-bound and unable to walk so he is brought to St. Joe's ER. His medical history is significant for atrial fibrillation, hypertension, hyperlipidemia, coronary artery disease and the patient also has a colostomy bag he had a procedure done and they were unable to connect is

The offender returns to clinic today for a number of issues. 1. Diabetes mellitus type 2: This has been well controlled on oral metformin and the patient reports that she has no concerns in this regard. Last hemoglobin A1c was 5.9 about a month ago and all other labs within normal limits except for a quite high LDL at 171. She has not been on cholesterol-lowering therapy in the past. In addition, her TSH was very slightly elevated at 4.740 which can be considered the upper limit of normal. She has not noticed any significant constipation, excessive fatigue, or cold intolerance but she has had continued trouble with weight gain and thinks she may benefit from some low-dose thyroid replacement. 2. Chronic low back pain: At

The patient was not seeking medical help for many years. She started to follow the physicians for the last few years. She had some CKD that is progressing to stage 5 recently. Her kidney disease is attributed to longstanding insulin dependent diabetes mellitus. She has never had a kidney biopsy done. Her last creatinine is 3.8 with an estimated GFR of 13. She had 4.5 proteinuria in July 2015. She is still not on dialysis yet. She will be starting peritoneal dialysis when it is medically indicated. She has not been evaluated for kidney or pancreas transplant in the past.

A review of his medical records indicates that he suffers from advanced dementia; he is now wheelchair dependent and needs assistance with all his ADLS. The facility nurse reports that he recently was treated with for pneumonia with antibiotic therapy. He has chronic left knee pain and left hip pain that is managed with tramadol. He suffers from co-morbidity of neuropathy-stable with medication, atrial fibrillation-stable, HTN-stable, depression-stable with medication.

Patient also, has history of hypertension, GERD, morbid obesity, anemia, and depression. She reported that the past few months, she has been feeling very weak and overall generalized deconditioning. Her ability to care for herself including her activities of daily living (ADLs), and her basic physical needs (like bathing, grooming, ambulation, meal preparation, transportation, errands, and housekeeping), had decreased, and cannot consistently carry them out.

History of Present Illness: Mr. A. O. a 66 year-old-African American male came in the clinic for a monthly routine follow up visit complaining of severe cluster frontal headaches that radiates to his left eye, pain level eight out of ten, on and off for three days lasting for 30 to 45 minutes. He stated that he takes Tylenol 1000mg orally every eight hours with mild relieve, and will like his blood pressure medications increased. Also, he complained of edema to the upper and lower extremities, and right hand pain when he tries to make a fist. However, he denied shortness of breath,