Medical Case Study: Cesar Sanchez

CP is a retired, 89-year-old male of upper-middle socioeconomic status. CP earned a degree in law to become an attorney. Prior to retirement he had 35 years of experience and his own practice. He had a right posterior hip replacement following a fall that fractured the right femoral neck. The fall occurred when he was walking from his home to the end of the driveway to throw away linens. Part of the linens slipped out from underneath the pile he was carrying, he stepped on it, fell and rolled down the driveway. He was taken to the hospital where he was to have a right hip replacement. The surgery went well, but he had to receive a blood transfusion. He has been transferred from the hospital and is currently at an inpatient rehabilitation center.

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.

During the initial assessment, Mr. Jose Rodriguez, a 36 year old Hispanic male, asked to be evaluated for stress and anxiety. He was accompanied by his sister, Adriana Barrera, and his wife Rosy Rodriguez. Mr. Rodriguez has a prior military history with little or no combat engagements. The initial assessment revealed that Mr. Rodriguez father whom he had a close relationship had passed away about a year ago. Mr. Rodriguez has been married for 16 years and has three children. On February 20, 2017 an initial assessment was conducted from 3:00 to 4:00 p.m. Instruments used were the Juhnke-Balkin Life Balance Inventory,and the Beck Anxiety Inventory.

In result of recent events, Scott Brink and Brendaly Sepulveda have been removed from AVP1. Scott Brink was removed for insubordination on 7/20 and Brendaly Sepulveda was removed for frequent absences effective 7/22. Which left the guard force at AVP1 with 5 open spot. I partnered with G4S recruiting and was able to conducted 6 interviews in 2 weeks. Which then resulted in AVP1 gaining 5 possible candidates, one of the recruits started training today (7/22). In effort to help with transition and training of officers, David Selan spoke with Joe Prula and he mentioned that AVP6 will only need 1 Officer after this Friday. Cameron is going to reach out to the AVP6 site leader, and ill re-assign shifts as needed. G4S is going to pay for

Wismely Ramirez-Jimenez, an 8-year-4-month old monolingual Spanish female was referred to the Children’s Evaluation and Rehabilitation Center (CERC) on April 18, 2016, for a feeding evaluation. Wismely was accompanied by her adoptive mother, Ms. Bello and biological father, Mr. Ramirez who served as the primary informants. Ms. Bello expressed concerns regarding Wismely’s choking and behavioral difficulties. She reported that Wismely “doesn’t chew and stuffs her mouth.”

Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications):Denies pain or stiffness in joints. Denies swelling, heat, or redness in her joints. Denies deformity of bones or joints. States no self or family history of arthritis. Complains of “achy fatigue” in lower legs at the end of the day. Uses a walker for increased stability. States she is “afraid of falling” so uses a walker at all times. States she fell in her kitchen late one night and bumped her head on the laundry room door. States she did not feel dizzy, just tripped over a kitchen chair with her walker. Called 911 for assistance but refused to go to the hospital for evaluation. Denies fractures or traumas to bones. States she has mild back pain when standing for prolonged periods of time. States she uses a shower chair to avoid fatigue in shower. States she bathes, grooms and dresses herself without assistance. Grandson assists with

Sergio Gonzalez moved from Mexico to Nova Scotia five years ago and got a job at a McDonald’s restaurant. Since then, he’s worked his way up to manager and handles all aspects of the business, from making burgers to managing inventory to scheduling employees.

Juan and Maria Lopez are Spanish speaking migrant farm workers who follow the crop cycles through the Western United States. Their son, Ricky, has uncontrolled diabetes, history of syncope, and has increasing weight problems. The Lopez family used to receive health care from a health services medical clinic, but now the children are enrolled in the Health Families public insurance program. Prior to having health insurance the family was able to maintain electronic medical records.

Mrs. Cabrera is a 64 years old women with history of high blood pressure, vertigo, and bilateral meniscectomy 3 years ago. Client is currently taking medication on a daily basis for her health conditions. Patient takes pain killer medication at least 3-4 times a week if knee pain is present after ambulating around the home for household activities. Client lives with daughter, grandchildren, and other family members. Patient has a supporting family nucleus, they agreed to make arrangement if necessary to avoid and prevent any potential fall risk.

This 56- year old claimant is filing a concurrent claim alleging disability since 11/01/2015 due to shoulder pain, difficulty weight bearing on the knees and ankles, arthritis, memory loss, back problems, COPD and a thyroid disorder.

In the last three weeks my client G was experiencing tingling in his hands, decreased fine motor control in his hands and increased weakness in his back and legs. This all led to decreased mobility and he was not in a wheel chair with limited ambulation (transferring to and from his bed or toilet and walking with PT two times day). This was a drastic change to his ability to care for himself and move about freely. This was impacting his emotionally and physically. Gas expressed embarrassment of having someone to help his to use the toilet and bath him. Due to his decreased mobility and spinal damage, he was losing strength, possibly at risk embolism and

Per medical and mental health records and consultative examination (CE) (2010-2011), he was evaluated multiple times for acute back pain radiating down the left lower extremity. He had back spasms and tenderness; the pain was controlled with medications. He ambulated using a golf club for a cane, was homeless and lived in a park. He did not have a job and received food stamps. Radiological examination (2011) showed a bulging disc in the lower back that affected a nerve.

Ronald X is a self-sufficient man who values his liberty. After he broke his leg, everything changed. The free and autonomous life that he was enjoying was now going to change. His medical comorbidity of artheriosclerosis causes him to be confused at times. The doctor and his children did not want him to be discharged home until they found an appropriate nursing home. Ronald X is aware of his problems and

There is a current court ordered between Mrs. Santiago-Leon and Mr. Glenn Hall Sr., father, to the children in which Mrs. Santiago-Leon gets unsupervised visit with the children at her home twice monthly. There is heightened concerned that since the allegations have been made, that there will be retaliation on the part of Mrs. Santiago-Leon against her daughter, Gina. Gina disclosed to SC DSS that her mother discipline her by hitting her with a broom. There were also disclosures made that Mrs. Santiago-Leon puts soap into the eyes of Glenn Hall Jr. Baths him in cold water, in an attempt to get him to calm down and that she has physical outside lock on the Glenn’s bedroom door and uses the lock to lock him inside his bedroom so that he can’t

I was requested to make an appropriate assessment after the functional decline related to recent fall and post hospitalization. Member is 78 year old Mandarin speaking female. Prior to this fall, this member only received three hours per day five