Chronic Right Illness Case Summary

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,

Based on the progress report dated 03/02/16 by Dr. Ozaeta, the patient has had a right knee corticosteroid injection one week ago. She had to take a Norco yesterday for right knee pain. She saw Dr. Cantrell, who requested 8 additional physical therapy sessions. She has low back discomfort, notable when sitting. She takes nortriptyline and an antihypertensive.

Per the medical report dated 07/18/16, patient is being seen for her lower backache, rated 7/10 with medications and 10/10 without medications. Current medications include Ambien 10mg; Maxalt-MLT 10mg; Norco 10/325mg; Evzio 0.4mg; orphenadrine 100 mg and gabapentin 600 mg.

Based on the progress report dated 08/23/16, the patient complains left knee pain upon walking. Discomfort was described as aching, tingling, intense, severe, continuous, pain, discomfort, increasing with movement and varying with activity. Pain is rated as 5/10 without medications and 4/10 with medications.

Per progress report dated 8/12/16, the patient was seen for her chronic neck pain and bilateral wrist pain. Current medications include Norco, Neurontin, Lisinopril, propranolol, clonazepam, fexofenadine, Asmanex, Nasonex, Relpax, Prozac, and Patard.

The patient is a 36-year-old individual who sustained an injury on 01/30/17 due to lifting.

After analyzing findings from the initial evaluation the patient’s primary issue is severe right hip/knee pain which is limiting his ability to participate in PT, as well as perform functional activities. Therefore, identifying the source of pain is the main priority since the patient’s pain is 5/10 at rest and 7/10 with bed mobility, transfers, and ambulation. Taking into consideration the high pain levels and unknown source; the patient was discharged and recommended to follow up with his MD. This being said, below are potential concerns involving the combination of medications and impairments during interventions if this patient remained in Neuro Clinic with minimal pain.

The patient was admitted of January 21, 2018 for physical and occupational therapy. M.G suffers from traumatic arthritis of the right hip,

Patient education provided. I explained to the patient that he had seen PT on 10/11/2016 and was given strengthening home program with Thera-Band. I encouraged patient to comply with PT advice. Also I review with the patient on his hip x-ray in 09/01/2016 and explain it to him that it showed joint space narrowing on the left more than right and that is early degenerated joint disease changes, so with that I encouraged patient modification of his activity avoid what triggers the pain, avoid vigorous or intensive exercise to the affected area. Take medication as directed. Running five miles that is the kind of activity he can reduce to like two miles daily. Walking, stretching, and prolonged standing limit to like one or two hours daily. No prolonged standing, like four hours _____ or even like all day based on patient report. All questions were answered. General measures were discussed sometimes like rest, ice, and take medication as directed. Again, I discussed about Indocin, Keppra indication and adverse side effect with the patient. Will follow up with him in 180 days for his chronic left hip pain. I offered blood work of CRP and ESR, patient declined it. Will continue monitoring his chronic hip pain in 180 days. I also reviewed the lab with the patient and his Keppra is 17.3 and 1000 mg twice daily, which were checked on 11/18/2016, it is at therapeutic level. Will follow up with him in 180 daily for his

The patient was admitted into the hospital. In the morning after admission was taken to the operating room where she under went open reduction internal fixation of her right ankle fracture. She had an uncomplicated post operative course and gradually returned to assisted ambulation, she was then discharged in good condition.

12/18/15 Progress Report indicated that the patient presents with back pain radiating down his right leg; lower backache and right hip pain. The pain is 10/10-scale level without medications and 9/10-scale level with medications. His quality of sleep is poor. His activity level has remained the same. Current medications include Lidocaine 5 % patch, Cymbalta 30 mg and Vimovo Dr 500-20 mg.

Recommendation was made for second generation oral anti-inflammatory drug, pain medicine, continuation of physical therapy with acupuncture, steroid injection, and continuation of home exercise.

DOI: 1/12/2016. Patient is a 51-year-old male plumber who sustained injury to his left shoulder and hand while he was walking towards the stairs when he slipped on ice.

DOI: 10/14/2009. Patient is a 44-year-old female hospital medical records clerk who sustained a work-related injury after tripping over garbage can and fell on her right knee on 02/07/2010.

2007). Chronic pain could act as a barrier to teaching/learning as well as affecting her ADLs and IADLs if not well controlled and not well managed. (Kozier, 2014). Inactivity can increase the risks of obesity, diabetes, cardiovascular diseases and cancer (NIH, 2012), and prolonged bed rest will increase the risk of developing DVT, circulatory complications, atelectasis, pressure ulcers, constipation and muscle atrophy (SHHC, 2005). Malnutrition/high sodium content put the patient at risk for nutriment deficiency (vitamins, iron, calcium, etc.), lack of energy, deficit in self-care, impaired skin integrity, activity intolerance, delayed wound healing and susceptibility to infection, cardiovascular diseases, stroke, kidney failure (Lewis, 2014). Mrs R lives alone which puts her at risk for falls, social isolation, depression, poor nutrition, inability to keep up with daily chores and housekeeping (neglect), medication management and economic issues (BJGP, 2007). Resources: She has good social support from her daughter and granddaughter, her oncologist at the CLSC and mainly from her friends through social