Patient Ms. A. H. admitted with hopelessness, and pain. Complains of anxiety over financial situation in her family. Introduction. Patient Ms. A.H. a 65-y.o. female, 62” tall, weight 182 Ibs. Hispanic origin. Had received medical care at community free clinic until age 65; now on Medicare. Medications: 1) Metformin, 500 mg, BID, PO; 2) Ibuprofen, 800 mg, p 8 hrs., PO, not to exceed 3 doses/day; 3) Verenicline (Chantix), 1 mg, daily, PO. 4) Budasonide (Simabacort) MDI, 160/45, 2 puffs daily; 5) Fluoxetine, 40 mg, PO, q AM; 6) Blood glucose monitoring daily. Assessment/Health Problems: 10 years diabetes, on oral medication, chronic degenerative osteoarthritis; chronic back pain; smoker: 1 pack/day. Attended diabetic diabetes education and
Medical History includes UTI, diabetes type 2, hypertension, GERD, glaucoma, diastolic heart failure, dysphagia, coronary artery disease with bypass surgery, chronic joint pain, and dementia Alzheimer's type.
Mr. Jones is in healthy condition and has family support to assist with recovery after surgery. He does not drink alcohol or smoke. The patient does have HTN and takes Cozaar 10 mg daily. He also takes one vitamin supplement per day. Mr. Jones walks 30 minutes daily with wife for
A progress note from Dr. Chweyah, dated 06/26/2017, indicated that the claimant presented for follow-up of gout, muscle weakness, and weight loss. He had ongoing weakness of the legs with knee pain. He stated that her weight drop had stopped. His current weight was 210 pounds. Objective findings showed a pulse rate of 105 with a blood pressure of 92/60. His BMI was 28.56. He was diagnosed with an acute pain in both knees, muscle weakness in the legs, chronic gout, and weight loss. A referral to neurology and medications were recommended.
This is 39 year old AAM. Patient is here with several complaints. Patient has no medical condition, or long term medications. Patient denies any other issues except as listed.
Susan is a 78 year old widowed lady who was admitted to a medical ward following an episode of coffee brown vomiting and breathlessness. Susan has a past medical history of chronic
The patient is a 70-year-old gentleman who presented to the ED with the complaint of numbness, noticeable changes mental status and is also noted glucose of 43. His medical history is significant for long-standing history of insulin-dependent diabetes mellitus, chronic alcoholism, chronic pancreatitis, paroxysmal atrial fibrillation, he is on no coagulation because of a history frequent falls, coronary artery disease, past history of a CVA, as well as COPD. Review of the chart and discussion with the patient reveals that he attends a daycare center five days a week. He lives alone, his sister and his niece do his food shopping for him. He prepares his own meals and he gives himself his insulin on the weekend otherwise it’s given to him
The first section to be filled out on the CMS 1500 form in boxes one through 13 include patient demographic information as well as insurance information. This information is captured to ensure the proper claim is associated with the correct patient.
The patient was admitted of January 21, 2018 for physical and occupational therapy. M.G suffers from traumatic arthritis of the right hip,
Claimant reports history of multiple medical complaints. Since the age of 60 she reports struggling with urinary incontinence, which impacts her functioning at work. She reports feeling ashamed and guilty that she is unable to control her urination and has the need to periodically utilize the restroom or go to her car taking time away from her responsibilities. In the past few years claimant has severe intensification of physical symptoms, including back pain, right shoulder and hand weakness, blood pressure, headaches, sleep difficulty, and depression-related fluctuating appetite, fatigue and sluggishness. She reports experiencing heart palpitations present (racing heart), dizziness, and fear of actual fainting, a feeling of choking and not being able to breathe, chest pains, nausea or intestinal pains, shortness of breath, tremors in the hands, hot flashes and tunnel vision. The claimant reports that she sleeps very minimally; averaging 3-4 hours of sleep per night on an interrupted basis due to physical and emotional pain. She reports that she has very poor mobility due to pain and depression-related poor motivation.
The American Healthcare System has been the topic lately in the news. This attention comes down to the executive order that President Trump has forwarded to the legislation. However, there is much debate going on about this executive order that has been issued. As stated in The New York Times, (Qiu,L) “Most people think of the term “bailout,” as a political pejorative,”(A17). This is currently one of the competing solutions to the “ObamaCare” or rather the Affordable Healthare Act, where a type of bailout has been placed into order as a solution to the deficit the AHA has had on the economy. Another solution is an executive order from President Trump to repeal and or replace the AHA, which in many views seems to be a desperate measure to
Patient is a nineteen-year-old college student working as a CNA. Patient’s has multiple chronic conditions such as Celiac Disease, Spina Bifida, Sjogren, Malabsorptive Disorder, Gluten Intolerant, Anemia, MTHFR Gene Mutation, deafness on right side, and Protein S deficient. Patient also has PTSD which contributed to depression, anxiety, and binge eating. Patient also complained of tiredness and being lethargic for 4-5 years and was put on Zoloft for depression. Patient is allergic to nickel and aloe vera. Patient is also at risk for breast cancer due to family history. Patient’s medications are Sertraline, Oxybutynin, Magnesium, Vitamin D, Vitamin E, Iron, and Vitamin B.
Per medical records (2008-2014), the claimant had a history of multiple medical issues, including migraines, right hand tremors, alcohol abuse, obesity, gastro-esophageal reflux disease (GERD), nausea, abdominal pain, endometriosis and degenerative changes in the left knee. In 2014, she was evaluated for hip
The Veterans Administration Medical Center (VA) hospital system has been in the national headlines for many years. This has generally not been in a positive way. Many issues have tarnished the reputation of the VA system including, in the distant past questions on sterilization issues reportedly resulting in veterans contracting Hepatitis C from a colonoscope (Tasker, 2011), to more current issues with access and timeliness of care for veterans ("Memo shows VA gaming appointments system to hide wait times", 2014; "Nearly 100 patients died waiting for care from los angeles VA", 2017). Our local Veterans Administration Medical Center is no different and has recently been in the spotlight for
L.V. is a 51-year-old Hispanic female. She is 5’4 height and 150 lbs. Patient denies pain, discomfort, or chest pain during physical assessment. Patient is allergic to Aspirin she states that she gets rashes when she takes it. She was diagnosed with thyroid cancer 5 years ago and got her thyroid glands surgically removed. Patient denies the use of tobacco and drinks 2-3 beers on special occasions. Patient works for an American Restaurant as a server, she’s been serving for over ten years. Patient states that she’ll be getting her first colonoscopy next month and she just recently got her yearly mammogram done and results were normal. Immunizations are up to date and she gets the flu shot every year. Patient has four daughters and has been happily married for 20 years. Patient denies using glasses or contacts she visits her optometrist every year and has never had a problem with her vision.
This patient has a regular pattern of this disease and does not want to take medication because he has adapted to this lifestyle of highs and lows. Over time the patient cannot resist any help and will make a change to better their lives.