Psy 230 Week 5 Nursing Care Plan

The first patient I witnessed was a 25 year old female. Pertinent patient medical history is anxiety, depression, and sleep dysfunction. The referring diagnosis is Chondromalacia of the right patella, which is also known as runner’s knee, is a condition where the cartilage on the undersurface of the kneecap deteriorates and softens. The physician who referred the patient, Victor N. Egwu, MD, orders the PT to evaluate and treat three times per week for four weeks. Right knee ROM and strengthening exercises should be done to treat patient. The PT evaluation justification history includes 1-2 person factors examination is addressing three or more elements. The clinical presentation is stable. The clinical decision-making is low co-morbidities.

Per the Ortho Agreed medical Re-examination report dated 11/15/16, should patient finally have laminectomy and hardware removal, he will be re-evaluated for maximum medical improvement.

Health History: A 25-year-old male injured his left knee in a recent skiing accident. The patient stated that he lost his balance because the inner edge of his right ski got caught while skiing. This resulted in the right leg being externally rotated followed by and audible “pop” as he lost footing. By evening, the right knee joint had become swollen, causing intense pain. The primary care physician referred the case to an orthopedist.

The patient underwent repeat MRI of his right knee on 1/28/16. As per office notes dated 7/25/16, review of system revealed that the patient has a history of weakness, shortness of breath, joint pain, muscular weakness, stiffness and muscular pain, headache and dizziness, as well as nervousness. The patient presents today stating that he would like to have his rod removed. He says that his right knee continues to give out on him and he wants to go on longer than 2 mile hikes without having knee pain and feeling instability. Examination of the right lower extremity revealed that the patient’s incisions are clean, dry, intact, and well-healed. The patient’s knee demonstrates discomfort with patellar grind-the symptoms are consistent with his last several exams, and are relatively unchanged. Knee is stable to varus and valgus stress, however, valgus stress does cause some discomfort on the lateral side. Distal neurovascular status is intact. Impression includes right displaced comminuted fracture of shaft of right femur, initial encounter for closed fracture; right chondromalacia patellae, right knee, and right sprain of other specified parts of right knee, initial

Per the AME report dated 07/08/15, the patient was deemed P & S with regard to her right knee and lumbar spine as of this date. Future medical care includes ongoing exercise program, occasional orthopedic visits, brief periods of PT, anti-inflammatory medications for flares, prescription medications and periodic injections.

Per the medical report dated 02/24/16, the patient had some left knee pain and swelling. On examination, there was some mild swelling along the anterior proximal tibia. He can flex to about 110 degrees and extend to 10 degrees. Of note, X-rays demonstrated plateau fracture fixed with plate and screws in good alignment with early callus. Medications include amlodipine; cefadroxil; diazepam; meloxicam; oxycodone/acetaminophen; rivaroxaban; and sertraline. Diagnoses include status post open reduction

Per AME dated 09/09/2013 by Dr. Luciano, the patient has reached Maximum Medical Improvement from an orthopedic standpoint and the patient has a total of 42% whole person impairment.

Per the progress report dated 8/4/2016, patient returns with improving symptoms to her left knee and has been undergoing post-operative physical therapy times seven visits and has been utilizing Transcutaneous Electrical Nerve Stimulation (TENS) unit as well. She does still experience significant intermittent post-operative pain which she currently rates as 6/10 in intensity. Patient remains on her current oral analgesic mediations

In these patients, 100% complained of knee pain, 33.1% of limping, 29.7 % of joint enlargement and 43.2 of crepitation. On clinical examination 52% had knee pain, 65.4 patellar crepitus, 48.6% joint enlargement, 48% joint stiffness and 50% joint malalignment.

12/18/15 Progress Report by Dr. Fuhrmeister described that the patient has right knee pain with radiation to the right leg. She is s/p right knee arthroscopy on 04/22/15. MRI of the right knee on 04/11/15 reported a lateral meniscal tear. It was recommended to have an MRI of a right knee and try PT, over her last visit on 11/16/15. The patient is requesting refills on medications. Her current medications include Opana 15 mg, Topamax 100 mg, Zofran 8 mg, Ambien 5 mg, Paroxetine HCL 20 mg, Omepreazole 40 mg, Baclofen 10 mg and Hydrocodone 5/200 mg. The patient is currently in pain at 5/10-scale level. The patient stated that hydrocodone for breakthrough pain provides inadequate pain relief. The note indicates that the patient is fully aware of risks of narcotics and potential side effects were discussed. There is constant burning and throbbing pain from the knee down laterally. Physical examination revealed an antalgic gait with a limp. She is wearing a brace on the right knee. ROM of the right knee is decreased. There was tenderness to palpation over the right knee. Treatment plan included medications, increase hydrocodone 7.5/325, PT 3 X 8, MRI, and follow-up with surgery. Follow-up is in 1 month.

The patient’s chief complaint is pain to the left anterior area of his right knee.

O: Right Knee: antalgia, no malalignment, no atrophy, swelling in the back of the knee, no ecchymosis, no erythema; no effusion, no warmth,

The patient stated that he began experiencing painful swelling in his right knee over a decade ago. A large mass grew around the knee and he underwent a total knee arthroplasty. Not long after the arthroplasty of his right knee, he began experiencing similar symptoms in his left knee and right elbow.

As per AME report on 3/16/12, the patient would benefit from resumption of weekly individual therapy sessions as needed over the course of the next five years, as well as medication management sessions on a once-monthly basis as needed over the course of the next five years to reach and maintain minimally acceptable level of functioning.

DOI: 4/18/2002. Patient is a 56-year-old male welder who sustained cumulative trauma to multiple body parts from lifting/carrying.