Nursing Case Study

At today’s visit she is seen at Tiffany hall SNF. She is found in her room. She is awake and alert and oriented. She c/o of pain in her hips and knees, that she describe as achy with a severity of 5/10, the pain does not radiate but does affect her ability to ambulate, she is using a wheelchair. Her pain regimen is Lortab 7.5 mg p.o every 4 hours. She reports that she has increased hip pain when she sleeps on her mattress because she sinks in her mattress. She is schedule to follow up with her orthopedic doctor Dr. Shute.

By 03/18/2016 Ms. Esru Wong verbalized to me that her pain is increasing however, is been control by medication.

Beru has limited motion of the back and cannot engage in heavy lifting, pushing, pulling and extensive squatting without risking injury. She suffers from neck pain and headaches when sitting at her work station for extended periods of time. Chronic back pain associated with her disability makes it difficult for Beru to rise and stand from a seated position quickly.

She reported body discomfort and hand and knee pain; she took over the counter medications for pain control. She stated that she had mobility difficulties as well as trouble with memory, concentration, understanding, completing tasks, following instructions, and getting along with others. She did not handle well stress or changes in routine. She used the computer at the library on a regular basis, and was able to walk and ride a 3-wheel

The patient experienced the same amount of pain and felt the same as the initial assessment day. The therapist started the treatment by placing the hydrocollator on the patient’s lower back for 10 minutes. And for the next 40 minutes, Manual Massage Therapy such as Swedish massage, Joint Mobilizations, MET (muscle energy technique), and Fascial Release techniques were performed in the lower back, Gluteal region, and legs. As for the homecare, the patient was instructed to perform Hamstrings and Gluteal muscle stretches, and strengthening exercises to strengthen the Abdominal muscles (Table 2). In addition, the therapist recommended the patient to use the heat packs and to support her lower back during her daily activities.

Selma Martinez Rojas physiatrist evaluated me on September 11, 2015. She ordered therapies and medication to see if the pain could be controlled or lessened since the MRI showed a degenerative condition. However, pain has not decreased. In her statement of January 5, 2016, Dr. Martinez Rojas says “Patient complains and disease is aggravated by his position on his employment that requires prolonged standing ambulation and heavy objects carrying”. In addition, the work requirements indicated by my supervisor in the Duty Status Report form exceed the limits indicated by Dr. Martinez Rojas. For example, in one day I am expected to stand and walk continuously for 3 hours and drive a vehicle continuously for 6 hours. Dr. Martinez Rojas indicates that I can only stand for 1 hour, walk intermittently for two hours and drive a vehicle intermittently for 3

Activity limitations for the patient are ambulation and general mobility. As we can see from the table, her lack of upper extremity range of motion has disallowed her to perform overhead activities. Her lower extremity neuropathy accompanied by decreased arthrokinematic mobility and weakness has severely decreased her ability to ambulate. These activity limitations lead to various participation restrictions including; inability to stand for prolonged periods of time, a requirement for her job, and, inability to participate in her usual leisure activities such as dancing and nature walking.

While in hospital, Ms Catherine made a satisfactory recovery and was able to walk with the assistance of Katie. Her pain has been also settling, but she occasionally complained about back pain. Her daughter requested us to provide Ms Catherine’s

She has a lot of difficulty kneeling or squatting or climbing one flight of stairs. She can only walk short distances. The patient is able to continue performing regular work.

She is doing pelvic floor PT, without benefit. She is to return for 1 more visit after the planned pudendal nerve block. She wants to restart pelvic floor PT at a different center.

The patient states that he can only walk for a few minutes and then his buttocks start hurting him and he has to stop, which suggests spinal stenosis per physician. He has numbness along the feet which could also be due to some neuropathy. The patient had MRI in 2014. The patient does have a hot and cold wrap and a two-lead transcutaneous electrical nerve stimulator unit. The patient does need a back brace. He does have a neck pillow, as well as neck traction kit. Chores are not being done. Lifting is curtailed to less than 25 pounds. The patient is sitting most of the time around the house. He is standing and walking no more than few minutes at a time.

Patient has no treatment since the last visit. There is increased pain and weakness. The patient presents in mild distress. The patient has difficulty rising from sitting. The patient moves with stiffness. There is mild tenderness on the lumbar, lumbar-sacral and sacral with spasms. Gait is antalgic.

As per progress report dated 5/2/16, the patient returns for lower backache. She rates her pain with medications as

I reviewed the medicals and I reviewed the testimony from the last hearing. Basically I got the claimant to say he had not worked since the accident, that is the main basis for the fraud claim because we have evidence of him working in the photograph that Dean took, but I also had him testify that he was honest and truthful with regard to his work activities and his physical complaints when he spoke to each of his doctors. So I looked at the medicals to see if there were any discrepancies between what he told the doctors and what we have on the surveillance material. He generally complaining about having pain in his neck and shoulder. His shoulder is sore while sleeping and there is a report of him saying he has difficulty lifting over his head or it aggravates his pain which I believe was what he told Dr. Delsavio on 03/30/17.

The patient reports she has had left hip and knee pain for the past 6 months.