Pt is seen in the ER room and states that he is tired and had tremors so he came to the ER to be on the safe side. Daughter also states that he had tremors in the morning and. Patient's CC is that was tired and had tremors in the morning. States that he stays alone, was worried, and has no past history. Assessment of the head shows no sign of deformities or trauma. Neck shows no sign of deformities or trauma. Chest shows no sign of
On Exam: BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the
On 5/30/18 I met Mr. Reid at the office of Dr. Rampersaud. I explained that the insurance carrier is not getting the form filled out correctly regarding his narcotic medications. I asked his permission to meet with Dr. Rampersaud when they go back to the examination room and leave once we discussed the form. Mr. Reid agreed. He reports that since having the spinal cord stimulator battery replaced his pain is 60% better. He reports his pain level is a 6. He continues to have his legs give out unexpectable. He reports needing help from his wife to roll him over when he is in bed. He continues to use a wheelchair. Mr. Reid said he wanted to speak with Dr. Rampersaud regarding decreasing his medications at least for the summer. He feels the warm weather makes his pain more tolerable.
The carrier has denied coverage of an MRI of the cervical spine as not medically necessary. There is a letter to the member from the carrier dated 11/05/15. In the letter, the carrier states in part: “According to the American College of Radiology Appropriateness Criteria regarding MRI of the cervical spine, MRI may sometime be beneficial in patients with neck pain and no history of trauma and no neurologic deficits. If their neck pain is persistent and they have had findings of degenerative changes on plain radiographs and “following failure of conservative management only in select cases.” In this patient’s case, the patient has self directed her care, having seen specialists and chiropractors without a firm diagnosis
Based on the progress report dated 03/11/16, the patient presents with neck pain, causing sharp and pinching pain, rated as 2/10. Patient reports that she has been better since the facet nerve blocks. Symptom is alleviated by injections and medications, and exacerbated by
Based on the medical report dated 04/01/16, the patient complains of pain in the neck with radiation to bilateral upper extremities and pain to the lower back with radiation to the lower extremities with tingling/numbness and weakness. He rates his pain 8-9/10.
R.P. is a 74-year-old married Caucasian female that is a homemaker that lives at home with her husband. Reason for her care is due to a recent fractured left hip and left wrist. She stated that she slipped on a rug in her home and landed on her left side. R.P. reports pain being 10/10 and sharp and radiates all over body stating, “even the slightest touch of skin hurts so much”. It all began a few minutes after the fall. Pain is alleviated with narcotics (hydromorphone and morphine) and immobilization.
Patient has a history of a myocardial infarction (MI, or also known as a heart attack) in 2004, she had a hip pinning in 2005, and a traumatic amputation of fingers on her left hand in 1974 from a lawnmower accident.
On 7/15/16 I met Ms. Pletscher in the office of Dr. Easton. Ms. Pletscher had a cervical fusion on 6/15/16. Ms. Pletscher was driven to the appointment by her daughter. She was wearing a hard aspen collar. X-rays taken showed that there was good alignment with her hardware. She may now be fitted for a soft collar. The incision is well healed with no signs of infection. She will be allowed to start physical therapy after 7/29/16. An operative report was obtained. Ms. Pletscher had a list of questions. She is concerned about the left shoulder being lower than the right; she also said that it doesn’t seem to be tracking. I did point out that she had already been evaluated by an orthopedic surgeon and the MRA of the shoulder was fine. She agreed
On 2/21/17 I went to the office of Neurosurgeon Dr. Schell. Ms. Ostrander had arrived and left before I arrived. Dr. Schell will not speak with case managers. I called Ms. Ostrander. She said Dr. Schell looked at the MRI disc and told her the compression fractures to her Thoracic spine had not healed and she needs a vertebral plasty done. This is going to be scheduled. He also told her that she has compression issues in her cervical spine but he would deal with this after the thoracic spine is taken care of. Dr. Schell’s office is supposed to schedule the surgery. The MRI done on 2/16/17 with and without contrast showed that the mild compression fractures at the anterior superior endplates of T5, T6, T7, and T9 are healed.
Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.
Carolyn had concerns about a throbbing pain in her neck, shoulders and upper/lower back. She also had concerns about a slight pain in her wrist. Carolyn has had a previous history of multiple musculo-skeletal surgeries.
The patient tells me she was cutting an avocado on September 17th. She said she was using a knife to remove the pit of the avocado and was holding the avocado in her left hand, the knife in her right hand, and was trying to stab at the pit. Unfortunately, she missed the pit and cut her hand. She said the wound was to the area above her fifth metatarsal, more on the palm side, than on the finger side itself. She said right away it was extremely painful and she noticed after some of the pain dissipated, that she was feeling a little numbness there. She said initially she did think much of it, but when she talked to her husband about it, he was worried about the numbness and prompted her to go to the emergency room. She was evaluated at Exeter Hospital. There, the wound was irrigated. She had two sutures placed. She did receive a tetanus vaccine while there, as well and was sent home. She was told that perhaps there was a mild injury to the nerve, but they did not think that there was a true severing of that nerve. She said she did not think much of it. The cut seemed to heal fine. There was no redness ever. It does not, in her mind, seem to be swollen. However, just in the last week, has noticed worsening types of pain. The pain is not over exactly where the stitches were, but more proximal, as well as if she has her fifth finger fully extended, she feels pain