Patients : 24 Patient Gender : Female

help stabilize her moods has also been on an antidepressant to treat the bipolar. Client has cycles

He underwent an interlaminar injection in May 2015 which improved his lower extremity pain by 99%. This has lasted him up until 1 month when he has had recrudescences of pain emanating from the low back radiating intermittently into the left lower extremity in a sharp shooting fashion, average pain 5/10, and worse pain 81/0. The pain is frequent and is associated with numbness and tingling. There is some difficulty with walking. Over the past 1 month, the pain has been severe. Home exercises and nonsteroidal anti-inflammatory medications (NSAIDS) have not been effective in reducing his pain and the pain is severe at times and limiting his ability to lift and sit. Walking, exercise and standing increased the pain. Lying down reduce the

constant hunger, and frequent urination. She denies any pain, burning, or low-back pain on urination.

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.

She says that she is a feeling quite well at this time. She had a little bit of breast tenderness yesterday, but says that is gone and she is not noticing it today. For the last couple of days, she has had a little bit of spotting that she read online and thought that it might be implantation spotting. However, is concerned because it lasted these last couple of days. She describes it as a pink, light type spotting. No frank blood. No true menstrual cycle. No belly pain or back pain. No urinary frequency, urgency, or dysuria. She is not having any nausea or vomiting. She has not yet contacted Dr. Cervenka's office about the spotting. She is a G1 P0. She had stopped taking her prenatal vitamin several months ago, as she was unsuccessful at pregnancy. However, did start retaking

This week she reported she wasn’t feeling well. Client reported no changes in her medications.

She continues to take the following medications: GABAPENTIN 400MG , ASPIRIN 81MG, Oxaprozin 600mg and

Based on the progress report dated 03/02/16 by Dr. Ozaeta, the patient has had a right knee corticosteroid injection one week ago. She had to take a Norco yesterday for right knee pain. She saw Dr. Cantrell, who requested 8 additional physical therapy sessions. She has low back discomfort, notable when sitting. She takes nortriptyline and an antihypertensive.

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

Is up-to-date on immunization, however she unable to receive the pneumo vac or Zostavax due to being autoimmune. Reports chronic pain in both shoulders resulting in difficulties sleeping.

Pain was rated 7/10 in severity. Physical examination revealed decreased lumbar range of motion in forward flexion due to pain. Gait was antalgic. She had difficulty with heel walk and toe walk. SLR was positive on the left. Motor exam revealed weakness 4/5 of the extensor hallucis longus and tibialis anterior muscles on the left. Reflex testing was normal. Sensory examination revealed hypoesthetic region over the left L5 distribution to pinprick and light touch. Current medications included Gabapentin, Tramadol, Methocarbamol, Cymbalta and Synthroid. Treatment plan discussed includes lumbar laminectomy, discectomy, foraminotomy and partial facetectomy at L4-5, preoperative medical clearance and post-operative bracing.

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

Bianca indicated that she is taking several medications. Asking her and her doctor about them would be helpful to understand her concerns.

Last pap smear was a year ago and she reports self-breast exam monthly. She never had mammogram nor be pregnant before. She is regular with her period.

sexually active and uses a diaphragm for contraception. She takes no medications. She appears uncomfortable. Her