Meeting Client Report

On 7/30/2015, client walk in the social service office and CM completed Bi-Weekly ILP Review. In the meeting client appears she appeared her stated age and in good physical health. She was satisfactorily groomed & dressed. She constantly throb her forehead, she most of time space out and her affect is flat.

Social Services Meeting: On 11/21/2016, Ms. Medina and her children met with her assigned Case Manager for the family ILP Document Review. Ms. Medina is expected to meet with assigned Case Manage bi-weekly. Ms. Medina’s next ILP Document Review is on 12/05/2016. Case Manager encouraged Ms. Medina to continue attending meetings. Ms. Medina stated that she was a sad and upset, due to that her doctor informed her that she is not going to be able to work as a Home Health Aid due to a back injury. Ms. Medina stated that her doctor recommended that she would benefit from physical therapy and that she should avoid to lift anything heavy until further notice.

On 2/11/2016, CM met with the client for Bi-Weekly ILP Review. Client appears to be cooperative and friendly. She was alert, satisfactorily groomed, and casually dressed. She was very loquacious.

CM was out on vacation from 5/3/2017 to 6/14/2017. On 6/20/2017, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in proper attire for the weather. Her affect and mood was appropriate. Client maintains eyes contact appropriately and she was oriented to person, place, time and situation. Client continue to deny suicidal or homicidal ideation

On 8/1/2015, CM met with the client and completed Bi-Weekly ILP Review. CM inquires the reason client wasn’t available for face to face meeting. Client reported she had a scheduled doctor appointment the same day. Client in the meeting appeared her stated age. She was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting. She made eye contact appropriately and her mood was balanced and her affect was appropriate. The client is fluent in French and CM called the Language Translator.

CM reviewed the Other ILP Review. Client agreed and signed ILP. Next schedule appointment 12/27/2016

CM was out on vacation for the period of 5/2/2016 to 5/9/2016. On 5/19/2016, CM met with the client to update Assessment and to complete Other ILP Review. In the meeting client appears to be friendly and cooperative. She appears to have some cognitive impairment. Client reported WECARE/Wellness referred the client to see Dr. Larissa Lempert/Neurology. Next upcoming appointment is scheduled for 5/26/2016. During the meeting session, client was dressed appropriately for the weather and had good hygiene. She ambulates with a cane due to leg problem. Client affect was flat. Client denied suicidal or homicidal ideation.

CM was out on vacation for the period of 8/15/2015 to 8/24/2015. On 8/26/2015, CM met with the client to complete Bi-Weekly ILP Review. Client arrived a few minutes late. She was dressed appropriately for the weather. She was well groomed. She was cooperative and friendly. She appeared in good health. CM inquires how client has been doing since the last Bi-Weekly ILP Review. Client reported she went to Tillary Women’s Shelter for her personal belongings; unfortunately she was unable to retrieve all of her personal belongings. She was asked to come back on 8/27/2015 Client reports no community support.

Per verification to the provider’s office, the patient has attended 24 PT sessions for the left shoulder from 05/23/16 through

At today's visit she is home alone. She is awake and alert. She complains of burning, Shooting pain in right Buttocks and hip area that radiates down her leg. Severity 10 out of 10, she currently takes OxyContin 40 mg every 12 hours and Percocet 10/325 every four hours as needed. She states that her pain is very debilitating and prevents her from leaving the house. She ambulate's short distances with a walker but has to take frequent rest periods.She states that this pain regimen is not helping much. She was going to resolute for outpatient pain management but at the moment she's unable to get out to her appointments due to her sciatica pain. She complains of chronic constipation.

Recommendation was made for a left L5 transforaminal epidural steroid injection to see if this will help her pain more than the SI joint and piriformis trigger point injections. This would be for diagnostic purposes and potential therapeutic. She would like to schedule the injections.

2016, the patient states that she had inflammation in her left forearm, which was causing

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

DOI: 5/1/2015. Patient is a 57-year old male certified nursing assistant who sustained injury to her left shoulder due to rendering overtime almost everyday. Per OMNI, he was initially diagnosed with left shoulder sprain.

Pain in right arm and left shoulder. During clinical presentation patient was not distressed or anything blood pressure 114/76 mmHg, heart rate 96 beats per minute, respiratory rate 20 beats per minute and saturation of 100%. General signs were pallor, weight loss, fever (Hammer & McPhee, 2014, pp. 69-72). Patient reports a history of difficult with regular bowel movements, which has been an ongoing issue during her hospital stay.