Sample Of Nursing Case Studies

DOI: 02/27/2014. The patient is a 63-year-old male driver who sustained lower back injury while unloading foods and fell between the loading dock and rear trailer.

DOI: 03/08/2011. Patient is a 48-year-old male route sales representative who sustained an alleged work-related injury to his back, neck, lower extremity and abdomen which affected his psychiatric state while performing his duty.

DOI: 12/3/2012. The patient is a 49-year-old male route sales representative who sustained a work-related injury to his lumbar spine and shoulders while lifting a bread rack out of his truck. Patient is status post bilateral L4-5 laminotomy, complete facetectomy and foraminotomy on 01/14/15.

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

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.

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.

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.

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

DOI: 9/4/2014. The patient is a 51-year old male paint maker who sustained a work-related injury when he missed a step on a platform and fell, jarring his back. As per OMNI entry, he was diagnosed with lumbar sprain and lumbosacral disc degeneration.

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 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.

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.

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.

DOI: 8/6/1997. Patient is a 56-year-old male chief engineer who sustained a work related injury when he fell on a level on or against an object. Patient is status post anterior lumbar interbody fusion at L3-4 and L4-5 with infuse, diskectomies with partial corpectomies and left cage instrumentation per the operative report dated 04/26/04.

Review of diagnostic studies and medical-legal reports is included in the physician’s notes. Objective findings note that the patient is mildly obese and appears to be in moderate pain. He does not show signs of intoxication or withdrawal. His gait is antalgic gait and is assisted by cane. Lumbar range of motion is restricted with 50 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral bending, and 10 degrees of left lateral bending. All range of motion is limited by pain. There is tenderness noted in the bilateral paravertebral muscles. Lumbar facet loading is positive on the left side. Ankle jerk is ¼ on the right and 2/4 on the left. Patellar jerk is ¼ on the right side and 2/4 on the left side. There is tenderness noted over the trochanter and pain to the lateral hip with range of motion. Right side motor strength of ankle dorsi flexor is 4/5 and ankle plantar flexor is 4/5. Hip flexor is 5-/5. Light touch sensation is decreased over the lateral calf on the left. Patient has resting tremor of the left lower extremity. His medications are Prilosec 20mg, Celebrex 200mg, Neurontin 800mg, Flexeril 10mg, Duragesic 75mcg/hour patch, Viagra 100mg, Nuvigil 150mg, and Silenor 6mg, Evzio 0.4 mg, and Norco