Dental Clinic Case Study

Shortly the incision made off the weight bearing surface of the posterior heel. Guide wire from the 70 cannulated

Osteomyelitis, the infection of bone, would cause swelling in the foot, limiting the movement in her foot. It also

1000 Pt denied pain at this time and rate 0 on a scale of 0 to 10. Pt thanks me a lot for pain medication I gave her. Instruct the pt to report her pain early before it get worse so I can give pain medication. Pt verbalized understanding of the teaching. No sign of distress or discomfort at this time. Will continue to monitor………L.Gotora

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

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.

Intermittent right shoulder and left hip pain. I did give him an order for x-rays. I will review results with him when available.

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.

On 6/14/16 I met Mr. Blake at the U of M wound clinic, Midland location. Mr. Blake said over the weekend, the white end cap fell off his pin to the third toe. Since that time he reports an increase in pain to that toe. Mr. Blake reported that he called Dr. Biddinger’s office and he was told to come in on 6/15/16. Dr. Taylor examined the foot. He removed some calloused skin around the toes. Dr. Taylor stated the wound is completely healed now. He does not need to come back to the wound clinic.

Patient is diagnosed with pain disorder with related psychological factors and complex regional pain syndrome I of the right upper limb, chronic pain syndrome. He will follow-up in 4 weeks.

The x-rays of Plaintiff’s spine showed normal alignment, no swelling, no fracture or dislocation and normal lordosis of the cervical and lumbar spine. Plaintiff’s left knee x-ray also showed no fracture or dislocation, but moderate decrease in the meduial articular joint space. Plaintiff was given a general diagnosis of neck pain, back pain, low back pain and left knee pain. Plaintiff was prescribed 3 sessions per week for 6 weeks of physical therapy.

Based on the latest medical report by Dr. Sudberg dated 12/09/15, the patient complains of worsening right knee pain with clicking, right leg numbness and improving left hip pain. Pain is rated as 7/10.

Per the medical report dated 08/25/16, the patient reports that her condition is unchanged. She has tried rest, heat, ice, therapy, medications, injections, splint and surgery. Patient still reports weakness, stiffness, numbness/tingling, catching and clicking. Symptoms are severe. Symptoms are made better by heat and ice, and worse with overhead activities, reaching, throwing, lifting, typing, and gripping/grasping.

Based on the latest medical report dated 11/23/15, the patient reports that his bilateral feet pain is over the ball of the foot. He has increased pain with the first step out of bed, right greater than the left. He has increased pain with pressure over the area. He also reports occasional numbness and tingling. There is pain with prolonged walking. Patient is going to PT. He is taking Advil occasionally.

Clifton engaged in conversation with CM. Clifton mentions to CM that he received the wound a week ago, while playing basketball and placed a band aid (adhesive bandage). Clifton stated, “It got big and my home girl popped it and pus came out. She called her father who is a doctor, and he told me to leave it open and get blood work done so I won’t have my hand cut off”. CM acknowledged what Clifton conveyed, but he has no history of diabetes to cause the extreme of amputation. However, the present color of the wound being green and yellow shows that he is an infection and needs medical assistance. CM inquired if he cleaned the wound daily and change the adhesive bandage. Clifton responded, “I change the band aide once”. CM provided suggestions

His pain is made worse with standing or walking for longer than 15 minutes. His pain is