Sample Of Nursing Case Studies

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is

As per office notes dated 5/4/16, the patient is seen for bilateral elbow pain and bilateral wrist pain. She rates the pain as 3/10 with medication and 7/10 without medication. She is active for at least six hours a day and has energy to make plans. Her activity level has

Based on the latest follow-up evaluation progress report dated 03/02/16, the patient complains of right shoulder pain and stiffness. He states that his shoulder feels sore. He states that his pain is aggravated by the cold weather and over activity. The patient has not attended physical therapy for some time due to travel outside of the country. He is using an analgesic cream.

Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.

Per the IME report on 4/28/16 by Dr. Pierce Ferriter, the patient reports that he is actively treating with physical therapy and chiropractic treatment at a frequency of 3 to 4 times per week. The patient’s diagnoses include resolved lumbar strain, resolved cervical strain, resolved left shoulder strain and resolved right knee strain. There is no medical necessity for further physical therapy, orthopedic treatment of diagnostic testing based on examination.

Based on the medical report dated 03/31/16 by Dr. Schonwald, the patient reports pain in his low back, left lower extremity, right lower extremity, as well as in his left hand that originates at his left elbow and to his fingertips.

Based on the progress report dated 04/05/16 by Dr. Fieser, the patient complains of pain in the left knee, left ankle and left foot, associated with numbness and tingling in the left leg/foot, as well as weakness in the left leg. He describes the pain as sharp, cutting, throbbing, dull, aching, pressure-like, cramping, shooting and shocking with muscle pain and pins-and-needles sensation.

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.

The patient presents with chronic neck and low back pain status post MVA in 2008. He was ran off the rode while on his motorcycle fracturing his neck and lower back. Mr. Buchanan denies having radiating symptoms down either lower extremity. His pain is constant throughout the day making it very difficult to perform his daily activities. The patient has not had injection therapy or surgeries for his neck and back pain. The patient was told after his last MRI that he has arthritis in both his neck and lower back.

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.

The patient is 79-year-old gentleman who is brought in by his family due to complaints of left sided facial droop over the past 7-10 days. He also complained of difficulty swallowing due to pocketing of food on the left side of his mouth. There are no complains of weakness, loss of consciousness or syncope. The patient is also complaining of incontinence occasionally. The patient admits to having difficulty ambulating secondary bilateral lower extremity pain and swelling. The patient was recently in the hospital from April 6 to April the 9th with hypertensive emergency which placed in congestive heart failure. He also has some hearing loss. It is noted that he is noncompliant with medications at home. He walks with a walker at baseline.

Based on the medical report dated 02/26/16 by Dr. Skubic, the patient complains of constant sharp aching pain in his lumbar spine, rated as 7/10. The pain is aggravated by bending, twisting, lifting, and prolonged walking/standing and is alleviated by modified activity. The patient has difficulty performing activities of daily living (ADLs) which include dressing, standing, sitting, climbing stairs, walking, lifting, restful sleeping and driving. Treatments to date includes medications, nonsteroidal anti-inflammatory medications (NSAIDS), 5 PT sessions which did not help, braces and activity modification.