Patient Visit Summary Report Essay

A review of her medical record indicates a history of polyarthritis with associated pain to hips, knees and back that is affecting her functional ability and causing decreased mobility. She also suffers from co-morbidities of anemia-chronic, COPD-chronic, oxygen dependent, HTN-stable, sleep apnea-chronic, NIDDM-stable, and unsteady gait.

The patient has no family history of heart disease or diabetes, however both her parents are on medication for high blood pressure. Her paternal grandmother died of breast cancer at age 47. Her maternal grandmother

As soon as she will be able to sleep more and change her feelings about SAD, she will be able to feel better with her joint pain.

Patient “DD” is a 56-year-old woman who was admitted to a nearby hospital for respiratory failure. With the only previous medical history being chronic bronchitis, she was diagnosed upon admission with COPD, anemia, hypoxia, moderate anxiety, and dyspnea.

She has a medical history of severe RA, had an upper gastrointestinal bleed in 1993, and had coronary artery disease with a coronary artery bypass graft (CABG) 9 months ago. She lives alone but has three children whom live close to her. She is a widow and her father died of cancer at 62 years old and mother died from heart failure at 79 years old. She has a 50-pack-year smoking history but denies alcohol use. Ever since her CABG she has engaged in “very mild exercises at home.” Her medications are Rabeprazole (Aciphex) 20mg/day, Prednisone (Deltasone) 5 mg/day PO and Methotrexate (Amethopterin) 2.5 mg/week.

A. Bob concluded “Sometimes I feel like everything aggravates it”. He seemed to be moved emotionally, which was evident when he said: “It was kind of a devastating”. Not obeying a carbohydrate free diet, sedentary lifestyle, and not being compliant with medication regimen were the top things that could really exacerbate his diabetes. Additionally, stress can aggravate his condition, because it elevates the glucose level. When Bob is under a lot of stress, he is also less

MEDICAL UPDATE: Client continues to report arthritis in her left leg and hand, high blood pressure. She also reports she will need surgery but she is waiting to be housed.

Per medical records (2008-2014), the claimant had a history of multiple medical issues, including migraines, right hand tremors, alcohol abuse, obesity, gastro-esophageal reflux disease (GERD), nausea, abdominal pain, endometriosis and degenerative changes in the left knee. In 2014, she was evaluated for hip

Think of the fight-or-flight response. One cannot fight danger when one’s blood sugar is low, so it rises to help meet the challenge. Both physical and emotional stress can prompt an increase in these hormones, resulting in an increase in blood sugars. Stress is a contributor to diabetes, which should be well managed.

At today’s visit she is accompanied by her husband and private aide. Her husband reports that she is doing much better. He states that her pain has improved and she has not taken her pain medication since last visit. He states that her anxiety had improved extremely with the recent change in her Xanax. He states that he has hired 24 help for the patient and since she has not fallen. She reports that she is feeling well. The caregiver reports that the patient continue to suffers from hypotension and hypertension with variation in blood pressure. The patient also continues to suffer from chronic tremors as a result of her Parkinson.

A 79-year-old female present with her daughter for ongoing fatigue also noted to have lost 5 pounds over past 6 months. No night sweats or fevers. Pertinent past medical history includes severe, generalized osteoarthritis, hypertension, type 2 diabetes mellitus and depression. She is taking the following medications: acetaminophen 650mg every eight hours, Lyrica 75 mg twice daily; alendronate 70 mg once weekly, valsartan 320 mg once daily, fluoxetine 40mg once daily and insulin glargine 20 units once daily. Your exam reveals slight pale conjunctivae, a 2/6 systolic ejection murmur and generalized arthritic joints in her extremities. A point of care test results in a hemoglobin of 10.2 g/dL. Complete blood cell count is done; results

Because of the cold weather, she has started to complain more and more of pain this week. She is sleeping fair 6 hours, uninterrupted. The patient stated that she goes to the gym 3 times a week for an hour and a half, and she works

At todays visit she is accompanied by her husband. She is awake, alert and oriented. She complains of chronic pain in her hips and legs that radiate down to her feet. She describes her pain as as shooting, dull, ache. “she states, sometimes its like

able to tolerate side effects from disease modifying therapy. She also carries diagnosis of Diabetes

At today's visit she is found in her room sitting in her recliner. She reports chronic, intermittent, dull, achy, lower back pain. Her current pain regimen is effective for her pain according to the facility staff. The staff reports that the patient is sleeping more hours during the day. She has increased generalized weakness. No acute distress noted this visit.