Nursing Case Report

910 Words4 Pages
Due to delay in meeting with Mr. Reid, the adjuster approved submitting the report after our initial meeting.

INTERVIEW SETTING

On 8/24/17 I met Mr. Reid at the Saginaw Michigan McDonald's location. Mr. Reid arrived with his wife. He walks with her supporting under his arm and using a cane. At the time of leaving Mr. Reids son arrived and helped support him on the other side along with his wife.

MEDICAL FACTORS

Related:
Date Medical Condition Medical Treatment Medication Source
2012
Low Back Pain Epidural injections, spinal cord stimulator device implanted and medication Morphine 15mg BID, Elavil 50mg 1-2 QD, Motrin 800mg TID, Tramadol 50mg BID Dr. Rampersaud PMR

Unrelated:
Date Medical Condition Medical Treatment
…show more content…
He is supposed to be scheduled for some injections to his tailbone to see if that will calm things down. He was told by his urologist that the incontinence of urine is from the spine. He reports he was written a prescription for depends by Dr. Rampersaud.

ADDITIONAL CONTACTS

None

ATTENDING PHYSICIANS

Name: Dr. Rampersaud Pain Management
Address: 4800 S. Saginaw St, Flint, MI 48602

Phone: 810-733-7560
Last office visit: 7/18/17
Next office visit: 9/6/17

Name: Dr. Shah Neurosurgeon
Address: 4800 S. Saginaw St. Flint, MI 48602 Phone: 810-733-7560
Last office visit: unknown
Next office visit: no up coming appointment

Name: Dr. Arbogast PCP
Address: 4154 W. Vienna Rd, Clio, MI 48420 Phone: 810-686-3747
Last office visit: as needed
Next office visit: as needed

MEDICATIONS

Mr. Reid reports he is taking the following medications for unrelated medical issues:
Metformin
Simvastatin
Lisinopril
Oxybutynin 5 mg twice daily for urinary frequency

Mr. Reid reports he is taking the following medications for his low back pain:
Elavil
Motrin
Tramadol
Morphine ER

DURABLE MEDICAL EQUIPMENT

Mr. Reid had a spinal cord stimulator implanted on 5/11/16

ADL’S

Mr. Reid said he needs help changing positions, moving his legs, stand by assistance to supportive assistance when walking due to legs giving out. He uses a cane and a borrowed scooter. He needs help with dressing, bathing, cleaning, home maintenance, and yard work. He
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