The patient was admitted to the hospital by her daughter after discovering that she had abandoned her medication and was significantly experiencing adverse effects from the withdrawal. The patients’ medical history included renal dysfunction, anemia, malnourishment, back pain, and a family history of mental health. The patient has a psychiatric history of being previously placed in the same clinical structure eight months ago due to related issues including the failure to take her medication and increased levels of mental health conditions that led
Cherron session was interrupted when patient #2141 arrived to be dose, but was placed on HOLD. It is noted that the patient boyfriend had made a complaint against Cherron on her behalf but it is considered as hearsay as the patient did not address the issue on her own with a Supervisor. Cherron addressed concerns of the patient non-compliance with her counseling appointments as the patient haven’t been seen for the month of March, ongoing use of illicit benzos/other drugs, and non-compliance with daily dosing.
D-The patient reports she is stable on her current dose and haven't experienced any withdrawals and/or cravings. The patient further mentioned that work is going okay, but still exploring other job opportunities. This writer provided positive feedback towards the patient's recovery process. In addition, the patient reports she has to do a pneumonia test as it was suggested by her PCP today. This writer requested for the patient to detailed if she's experiencing any symptoms and would like to consult with the clinic medical doctor. Based on the patient, she reports she was experiencing some backaches, but now, feels okay. During the remainder of the session, the patient discussed her plans for the Easter holiday and also shared with this writer that today is her son birthday.
The patient arrived on for his counseling session. Reports stability on his current dose and denies the need for a dose increase or decrease when offered by the writer. The patient was made aware that he will be reassigned to counselor, Scott effectively immediately as his new assigned counselor will schedule his next session. The patient reports of no update with his medical pertaining to a referral to another PCP as he is currently still seeing the same medical provider.
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.
EMG biofeedback: Can be utilized to receive information related to motor performance, kinesthetic performance or physiological response
Cano, the patient is status post right carnal tunnel release. She has been on physical therapy for the last three weeks. She states she is doing much, much better. Her left hand will be operated on 5/03/16. She complains of severe insomnia. This has been chronic with headaches and chronic depression. She states she is hearing voices, hearing auditory hallucinations with paranoia. This started after the oral steroids. She is psychotic and severely depressed. There is a past history of post-traumatic stress disorder (PTSD), generalized anxiety, and chronic depression. Previous antidepressants included Celexa, BuSpar and Xanax. She states she has been clean. There is no evidence of any type of drugs in her. She brought what she had and had thrown those out and had detoxed a few months
Patient S is a seventy-eight-year-old male who presented to the ED in Rushville on October 25th with signs and symptoms of a stroke. These symptoms were leaning to the left side, a left facial droop, weakness in the left arm, and ataxia. The patient has no history of stroke. Patient S was admitted to 4-G in Memorial for a right-sided ischemic stroke. The patient has a history of atrial fibrillation (A-Fib), hyperlipidemia, bleeding problems, hypertension, sleep apnea, and a pacemaker. Patient S lives at home with his wife. Patient S was independent before the stroke. On October 13th, the patient had surgery of lumbar stenosis on L3, L4, and L5. The patient and wife reported increased serosanguinous drainage that soaked the dressing. Patient denied fever or pain at incision site. The doctor decreased Warfarin from 5 milligrams (mg) to 2.5 mg and prescribed a full dose of aspirin.
Polyuria: is more than normal or increased urine output. Water homeostasis is controlled by a complex balance of water intake, renal perfusion, glomerular filtration and tubular reabsorption of solutes, and reabsorption of water from the renal collecting ducts. When intake of water increases, blood volume rises and blood osmolality falls, lowering the release of ADH (arginine vasopressin, which promotes water reabsorption) in the hypothalamic pituitary system. With the lowering of ADH there is a rise in urine volume, which allows blood osmolality to return to normal. Urine containing large amounts of glucose has high osmotic pressure, which attracts water, so that urine output rises (osmotic diuresis).
01/11/16 Progress report by the requesting provider documented that the patient was unable to come to the appointment due to his physical condition and distance. Phone conversation with the patient was noted. He described his depression s mild. His sleep has been decreased. He uses CPAP machine. He enjoys being outside. He has occasional feelings of hopelessness. His energy and concentration have been fair. His appetite has decreased ad he has lost weight. He now weights 207 pounds. He denies any suicidal or homicidal ideation. Plan was to continue Pristiq 100 mg daily for depression. He also gets Temazepam, methocarbamol muscle relaxants, and Buspar. Patient education was discussed in detail about medication risks and benefits, adverse effects, side effects and therapeutic effects.
Respiratory. The client denies a recent history of significant breathing problems. Client states as a child she had asthma but that has since cleared up. She denies cough, sputum, shortness of breath with activity, wheezing, or pneumonia. Client states she has no history of exposure to tuberculosis. The client has a history of smoking. She smoked for less than a year in 2007. She states she smoked 1/20th of a pack per day and quit cold turkey. Client stated she had bronchitis once in June 2016. Her physician prescribed an albuterol inhaler and a steroid prescription. Treatment resolved the bronchitis. The client states she has limited exposure to secondhand smoke due to neighbors smoking on their front porches in the townhome apartment complex where she lives.
" When I missed my dose, I did not have any withdrawals. I felt fine, Charlene.....I am just tired of having to come there everyday and its affecting my work schedule. I tried to call you and I know you were busy as you just returned from vacation.....I have a lot going on. I do not need doctor to tell me that I cannot go down because I am still using." This writer explained to the patient as to why the doctor made the comment due to past consultation over the summer. The patient is aware of the clinic's concern, but does not feel to continue due to the risk
Medical records reviewed included Request for Authorization (DWC Form RFA) dated 07/20/17, Primary Treating Physician’s Progress Report (PR-2) dated 07/20/17, Mitchell, Utilization Review Request for Additional Information (RFAI) dated 07/26/17, and Mitchell, UR Notice of Retrospective Authorization
Patient is 52 year male with diagnosed with Schizoaffective disorder, Type 2 diabetes mellitus, Generalized anxiety, Gastro-esophageal reflux Constipation, Alert orient X 3, was and cooperative during SN visit. Denied SI, HI, V/H, A/H, self harm behavior and contracted for safety. Mood/affect flat. pt has poor family dynamic , a family that have not been supporting him. pt has been under CHD for financial managements. and A better life home care with his which provide him with daily skilled visit in provided daily assessments of patient vital signs, medication administration/management (assessing compliance of pre-poured medication), assessing patient’s mood, mental status, coping skills as well as safety which has in turn kept the patient out of any possible hospitalization this period. Patient continue on clozaril which requires to be carefully administered and monitored if any side effect.patient is also continue on Vistaril Oral 25 MG 1 Cap(s) by mouth twice daily AM & PM as needed for anxiety which he requires daily d/t being
The World Health Organization ranks headaches 19th among “causes of years lived with disability”.1 Patients that suffer from migraine headaches are more likely to have psychiatric comorbidities, a lower socioeconomic status and additional occupational disabilities, which additively create a diminished