Patient Case Report Sample

MRI of the lumbar spine obtained on 05/19/15 revealed at L2-3, endplate osteophyte formation and disc bulge contribute to a mild degree of spinal canal stenosis and a mild degree of bilateral neural foraminal compromise. At L3-4, a disc bulge eccentric leftward and endplate osteophytes formation are responsible for a mild degree of spinal canal stenosis, a mild degree of right neural foraminal encroachment, and a moderate degree of left neural foraminal encroachment. At L4-5, there is a diffuse disc bulge and endplate osteophyte formation which effaces the ventral aspects of the thecal sac and are responsible for a moderate-to-severe degree of spinal canal stenosis, a mild degree of right neural foraminal encroachment, and a severe degree of left neural foraminal encroachment. At L5-S1, a shallow disc bulge and endplate osteophyte formation contribute to a mild degree of left neural foraminal encroachment, without compromise of the spinal

DOI: 09/12/2014. Patient is a 45-year-old male vacation relief route sales representative who sustained a work-related injury to his lumbar spine from bending and pulling a bread product. Per OMNI entry, he was initially diagnosed with disc herniation at L4 to L5 with radiculopathy. He is status post extraforaminal L4 to L5 discectomy on 04/09/2015. He has been off work for nearly 2 years.

MRI of the lumbar spine performed on 10/30/14 demonstrated mild anterolisthesis and prominent degenerative changes at L4-5, resulting in contact and possible impingement upon passing L5 nerve roots bilaterally. There is moderate bilateral facet arthropathy at this level. Mild central canal narrowing is seen at L4-5. Mild chronic compression deformity, superior endplate of T12 is seen.

DOI: 12/19/2012. Patient is a 52-year-old female laborer who sustained injury to her neck, back, and right shoulder due to motor vehicle accident. Per OMNI, she underwent an emergency neck surgery with 5 screws at C5-7 and back fusion and rod placement at T8-10.

Chweyah, dated 08/11/2017, indicated that the claimant presented for a follow-up visit after his discharge from the hospital on 08/08/2017. He was admitted on 08/04/2017 due to normocytic anemia, pain in both knees, starvation ketoacidosis, hypertension, gout with tophus, and duodenitis. The esophagogastroduodenoscopy revealed erythematous duodenopathy, erythematous mucosa in the antrum, and small hiatal hernia. He had a colonoscopy which revealed internal hemorrhoids. Objective findings showed blood pressure of 112/86 with a pulse of 105. He was diagnosed with quadriceps weakness, pain in both knees, normocytic anemia, type 2 diabetes mellitus, hypertension, stable chronic kidney disease stage III, and bilateral impacted cerumen. It was noted that he can return to work on 08/16/2017 with limitations of not standing for more than 10 minutes at a time for 1

As per medical report dated 4/19/16, a lumbar MRI with and without contrast was requested to evaluate for a discogenic and/or facetogenic etiology for pain. MRI would also allow evaluation of conditions such as spinal stenosis.

Per the medical report dated 07/18/16, patient is being seen for her lower backache, rated 7/10 with medications and 10/10 without medications. Current medications include Ambien 10mg; Maxalt-MLT 10mg; Norco 10/325mg; Evzio 0.4mg; orphenadrine 100 mg and gabapentin 600 mg.

Per medical report dated 11/24/15 by Dr. Cano, the patient is complaining of severe numbness in the right hand, tightness around the right worse than left hand. She also associates this with dropping items. She is unable to button her shirts or raise her arms up to her elbows. This is continuous all day long. Also, associated is severe low back pain with numbness, radiation, and muscle spasm in the thoracic area, and numbness and radiation down the right sciatic nerve with severe low back pain. She continued to work, sixteen-hour shifts, seven days a week. At this time, she is unable to function. She states that she has had 24 sessions of physical therapy that has definitely helped her.

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

DOI: 9/30/1997. The patient is a 50-year-old female reservation clerk who sustained a work-related injury to her back and bilateral lower extremities when she tripped and fell.

Actress Purpose: The purpose of this document is to provide a thorough history of her character so she is ready to portray a patient with atrial septal defect. This document will prepare the actress for any questions that the medical student asks her (history of symptoms, family history, social habits, etc). Since our patient is supposed to be extroverted and talkative, we include a lot of “extra” information about her life.

Based on the medical report dated 04/14/16, the patient presents for medication maintenance. He reports ongoing pain, withdrawal symptoms such as increased pain,

Past Medical History: The patient has a history of end-stage renal disease secondary to IgA nephropathy, hypertension, alcohol abuse, biopsy proven liver cirrhosis, history of right leg cellulitis,

On Thursday, November 24, 2016 I reserved a call to talk to the patient in room 465D Vandunk ,Harold. the Observers is PCT Kojo antwi and the Nurse is Emilcar Ariello the patient is a one to one and on arrival I talked to the observer Kojo antwi siting with the patient. PCT Kojo told me the patient is very upset and wanted to talk to security. I asked the patient what he claimed was stole from him and he said about 1100 dollars. Then I asked him when was the last time he say it and he said 2 weeks ago right after he got married. I asked PCT kojo if the patient was confused at any time while you was sitting with him and he told me the patient shows signs of confusions. After I talked the patient and the observer and then talked to the nurse

Mr Johan experiences symptoms of panic attack when he feels self-conscious in front of other people when performing certain tasks. He reported feeling faint and had black out of thoughts during those episodes, whereby he was not able to think of anything. Both his hands would tremble and become numb. He would also be sweating but experienced no symptoms of pounding heart or choking