She has a mildly masked appearance of her face at rest. Her face continues symmetric at rest with good strength with smiling, keeping her eyes closed against resistance, and wrinkling her forehead bilaterally. She has good strength of her extremities. She has only mild cogwheel rigidity of her wrists and elbows. She had only a minimal resting tremor of her right hand.…
Mary San Juan Hospital is in receipt of a denial letter dated December 26, 2016 for acute inpatient care provided on the above dates. The denial is based on the premise that it was medically unnecessary. However, the hospital has determined that this acute inpatient admission was warranted and supported by clinical documentation in the medical chart. The treating physician exercised their expert opinion in electing to admit this patient out of concern that his symptoms were attributed to an acute or escalating clinical condition.…
CC Sore throat and congestion. Lesion on left toe. Puncture wound. Poison ivy.…
Dear ___ [NAME] Thank you for the kind referral of ___ [NAME] who I caught up with this week with regard to her left os naviculare injury which she has been having now for three to four months but slowly worsening on return to support. She occasionally has a stabbing pain when she is sitting or just walking around with no shoes on and as you are well aware with her scan presenting with some tibialis posterior tendonopathy and os naviculare information. As in general history background ___ [NAME] told me that she has had a left knee arthroscope in recent times which she still rehabbing with a physiotherapist at this present time currently wearing New Balance 761 tennis shoes and walking and jogging around in her New Balance 1080 neutral runners.…
A 35-year-old Caucasian male came to the hospital by Life-Flight after sustaining a compound fracture to the left leg below the knee. Upon the paramedic’s arrival, the patient explained that he was hiking and fell down a hill, injuring his left leg in the process. The patient wrapped the leg with a shirt in an attempt to stop the bleeding, and also to stabilize the fracture. According to the patient, he began to have intense pain at the site of injury hours after the incident (Pietrangelo, 2012). Additionally, after the injury he suffered from a rapid heart rate, severe swelling and pale skin (Pietrangelo, 2012).…
D.J. is a 77 year-old African-American male patient who was transferred from the MICU to the CCU unit after experiencing respiratory distress. He had been admitted for moderate dehydration. The previous nurse reported that the patient’s breathing had become rapid and labored with the usage of accessory muscles. Also, reporting that his body temperature was extremely low and that his heart rate would not decrease below 200. My preceptor and I performed a head-to-toe assessment and noticed that his level of consciousness was diminished.…
DOI: 10/31/2014. This is a 41-year-old male customer care supervisor who sustained injury to his left quadriceps and knee when he slipped on mud and landed on his knee. As per office noted dated 7/15/16m the patient spoke with Durable Medical Equipment (DME) company last week. It was noted that the patient is still waiting for brace. The patient is doing physical therapy and home exercises.…
Describe the Beneficiary's Medical Profile (follow Optimal's writing guidelines) * The beneficiary was 67 year old woman with a history of chronic venous stasis and chronic non-healing leg wound. She went to the Emergency Room (December 27, 2013) complaining of bilateral lower extremity swelling (cellulitis) and pain. She had a severe infection (septic shock), was admitted to the hospital, was seriously ill, and “ended-up with bilateral above-knee amputation.” She developed multiple problems, including kidney failure (required dialysis), and cardiac problems (atrial fibrillation).…
She wants to know why she did everything she could but still ended up with this unfortunate disease. “I received weekly Ayurvedic body therapy, I re-examined all my herbs and supplements with my integrative internal medicine doctor. I took another hard look at my diet, ate more healing foods (like warm milk with ghee, rose petal jam, coconut oil and classic Ayurvedic chavanprash) and I ate less animal protein. I backed off on the harder-core aspects of my exercise regimen in order to nourish my whole self. ”(32)…
The patient is of the Hispanic background. 1. This patient is at risk for infection or developing sepsis due to being 10 days postop for an amputation. Complete blood count measure how many white blood cells are circulating in the bloodstream.…
Critical limb ischemia (CLI) is serious form of peripheral arterial disease (PAD). The incidence of CLI increase with age and atherosclerotic risk factors such as, diabetes, cigarette smoking, obesity or hypertension .The prevalence of CLI is approximately 12% in the adult population especially men compared to women (Davies 2012).The clinical presentation of this disease range from intermittent claudication , rest pain, ischemic ulcers, or gangrene. CLI could lead to severe disability such as amputation or even death (Rosales, Mathewkutty & Gnaim 2008).…
He was rushed to the local ER where his parents were informed that he would need surgery to correct the fracture. Between his admission to the ER and his transfer to the surgical unit, a several hour process, Dominique did not receive any form of pain medication. His mother was frantic that he was in pain and tried to advocate for him but was told by the physician in the ER…
1. Medical Conditions/Diagnosis: Pa Dx include: Kidney failure, CRF, Diabetes, Edema, Anemia, and HTN. The reported effects includes: severe weakness, swelling and fluid retention in her extremities and in her abdomen. Pa receives ESRD - dialysis 3 days a week.…
On examination, the patient has normal strength and tone. No involuntary movements are noted. Her movements appear purposeful and normal, specifically there is no tremor or shaking and they are not slow. No fasciculations are noted. Tapping muscle tendons elicits a normal…
HISTORY OF PRESENT ILLNESS: This patient is a [_:03___] 15-year-old male he for followup with his right ankle fracture. He had seen Todd Reilly, MD last week in initial consultation. He had a medial malleolus fracture, which is below the weightbearing surface of the ankle. Apparently, at that time, options including surgical and nonsurgical options were discussed with the patient and they chose nonsurgical options. He is here for followup x-ray of the ankle.…