Case Study: Chief Complaint

Normocephalic atraumatic. Pupils equally round and reactive to light, extraocular motions intact. Oral cavity shows oropharynx clear but slightly dried mucosal membranes. TM (tympanic membranes) clear. Neck, supple. There is no thyromegaly, no JVD. No cervical supraclavicular, axillary, or inguinal lymphadenopathy.

PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.

Prescription Drugs – This list can be quite exhaustive, but mainly contains all the tablets prescribed by the GP with regards to depression, sleeping tablets e.g. Tamazepan, Diazepam, and Valium

Visual fields are full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation, and movement. Tongue and uvula are midline. Normal auditory acuity. Normal shoulder shrug.

The claimant was alert and clear. He was orientated to person, place, time, and situation. His remote memory was poor. He was only able to remember one of the three words presented to him earlier in the evaluation. His immediate recall skills were above average for a forward recall task (8) and below average for a backward recall task (4). He was able to add, subtract, and multiply correctly. His word associations were poor. His abstract knowledge was fair. He somewhat interpreted two of the three proverbs presented. His social knowledge was good. His social reasoning was good. He was able to correctly identify the current president and his immediate predecessor. His concentration and persistence on task was average. His pace of task was fair.

On 04/10/2018 I received an informal complaint from you, dated 04/10/2018. The topic of your informal complaint was a missing hobby craft that you claim to have dropped off at the Santa Cruz Unit programs office to COIII Keaton. In your complaint you stated that on March 1st you gave COIII Keaton a painting that you wanted to be included in a Tedx logo contest that was being held on March 2nd. You stated the painting needed to be turned into COIV Contreras, who was not in the programs office when you dropped the painting. You stated that COIII Keaton took possession of your painting, and told you that he would take it to COIV Contreras. You stated that on April 6th, Inmate Mounla #140057 informed you that your painting was lost, and that she confirmed this by asking COIV Contreras, COIV Flores, COIII Keaton, and Deputy Warden Theodore. You stated that inmate Mounla informed you that COIII Keaton stated that he did receive your painting, and that he immediately put it on COIV Contreras desk. Your proposed resolution was for your painting to be located.

She converses appropriately. Blood pressure 92/60 supine. Blood pressure decreased to 72/50 standing. Pulse is 90 and regular. Weight 113 pounds. She has a normal appearance of her face and does not have a masked appearance of her face. She has good strength throughout her face. She has good strength of her extremities. She has only minimal cogwheel rigidity at the left wrist, but no cogwheel rigidity at the right wrist. She has no tremor of her hands. She moves her extremities freely and with normal speed. She is able to rise on her own from a sitting to a standing position, only minimal bradykinesia of standing. She walks fairly freely and there is a normal cadence of her gait. She did not have dyskinetic movements of her extremities. She is able to walk, including turning without losing her balance. She does not shuffle her feet when walking. She does not have en bloc turning. She has good posture stability

In your grievance filed at Central Unit, you claim COIII Forman refused to provide you staff assistance to help you gather evidence for your pending disciplinary hearing. You are requesting that COIII Forman receive sanctions and retraining on being a Disciplinary Coordinator.

Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation and movement. Tongue and uvula were midline. Normal auditory acuity. Shoulder shrug is normal.

The most common prescription drugs are hydrocodone, vicodin, oxycodone, marijuana, and adderall. These drugs range anywhere from painkillers to narcotics to depressants and stimulants. People use statin drugs,

Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation and movement. Tongue and uvula are midline. Normal auditory acuity. Normal shoulder shrug.

In your grievance filed at Central Unit, you claim ADC is denying you access to the courts by refusing to provide you with case law. Your resolution is to be provided with case law.

Eve an 80 year old woman has been admitted to hospital due to a fractured hip in a mixed surgical ward. Post assessment, the team has come to a conclusion that it would be best for Eve to have a hip replacement; the patient has been informed and she opted for the procedure to take place. However, Eve has early signs of Alzheimer’s disease. Alzheimer’s disease affects parts of the brain as well as causing brain cells to be damage (Alzheimer’s society, 2014). An individual who is suffering from this disease experiences symptoms such as she short-term memory loss, finding it difficult

Regarding this individual's right facial numbness and tingling, she seems to have had these on at least a weekly basis over the last four years. I therefore doubt that they are TIAs, as I would expected to have gone on to complete her stroke if it were. It is certainly possible that these may be simple sensory seizures. She did have a couple episodes of confusion and problems speaking or concentrating, which may represent seizure activity as well. She states that she does occasionally feel confused or foggy headed for several minutes at a time.

Two days following surgery, Mrs. K developed symptoms indicative of cognitive impairment and include: agitation, restlessness, attempting to remove her urinary and intravenous catheters, and laughing and crying unexpectedly (emotional lability). Mrs. K’s daughter has been unable to