Immunosuppressive Therapy Case Summary

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

Chweyah, dated 08/11/2017, indicated that the claimant presented for a follow-up visit after his discharge from the hospital on 08/08/2017. He was admitted on 08/04/2017 due to normocytic anemia, pain in both knees, starvation ketoacidosis, hypertension, gout with tophus, and duodenitis. The esophagogastroduodenoscopy revealed erythematous duodenopathy, erythematous mucosa in the antrum, and small hiatal hernia. He had a colonoscopy which revealed internal hemorrhoids. Objective findings showed blood pressure of 112/86 with a pulse of 105. He was diagnosed with quadriceps weakness, pain in both knees, normocytic anemia, type 2 diabetes mellitus, hypertension, stable chronic kidney disease stage III, and bilateral impacted cerumen. It was noted that he can return to work on 08/16/2017 with limitations of not standing for more than 10 minutes at a time for 1

He was diagnosed with liver disease a few years ago. He had a history of positive hepatitis C virus antibody. His hepatitis C virus PCR was checked on two different occasions and has been negative. He was evaluated by hepatology, Christopher Albers, MD at Tampa General Hospital for his liver disease. He had a liver biopsy done showing evidence of liver cirrhosis. Per patient's report, he was told that he is not a candidate for a liver transplant at his point. No evidence of abnormal liver function tests in the records and his coagulations were in normal range. He has chronic thrombocytopenia that has been attributed to alcohol use and liver disease. No history of hematemesis. He reports that he had endoscopy as part of the work up at Tampa General Hospital but he does not recall the results. His last colonoscopy was done this year at Tampa General Hospital. No reported malignancy, per patient's report. He also has imaging for his abdomen and pelvis but we do not have the results at this time.

Review of the medical record indicates that he had a MVA in 1977 with C4-5 injury that resulted in him been a Quadriplegic. Due to his bedbound and immobility status he has had multiple pressure ulcers over the years that have resulted in hospital admission and rehab stays. Other medical history include, HTN, hyperlipidemia, Sacral pressure ulcer, Right hip pressure ulcer, Constipation, depression. Bilateral arm contractures, bladder cancer, prostate cancer, urostomy and colostomy, aspiration pneumonia, neuropathy and MRSA.

PAST MEDICAL/SURGICAL HISTORY: As above. SOCIAL HISTORY: Status post heavy smoking, 50+-pack-year history. He quit 10 years ago. Status post alcohol abuse, quit 3 or 4 years ago. He lives by himself and no longer drives but has 2 daughters here in Miami who take him where he needs to go. FAMILY HISTORY: Patient’s wife died 14 years ago of COPD due to lifelong smoking. Brother has diabetes mellitus. Unremarkable family history otherwise. REVIEW OF SYSTEMS: No fever, no nausea, no vomiting. Patient has incontinence of bowel. No shortness of breath, no chest pain, no palpitations. PHYSICAL EXAMINATION: Well-developed, well-nourished white male who is alert and oriented x3. Wears bilateral hearing aids. Afebrile with blood pressure 130/70. NECK: No carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: S1, S2 normal. No murmur. No S3 or S4. ABDOMEN: Soft, nontender. No arterial bruits. No masses, no organomegaly. EXTREMITIES: No edema. No pulses present in the lower extremities. The right great toe is absent. The left great toe shows a 2 x 1 cm deep ulcer with redness around the toe with pus extruding. PLAN 1. Get consult with Dr. Beth Brian, Infectious Disease. 2. Follow up with Dr. Hirsch, Orthopedics. (Continued)

The patient is an 88-year-old gentleman who is brought to St. Joe's ER complaining of inability to walk. The patient 6 days ago began to having trouble walking with his walker. He reported left arm pain which radiated up his left arm. The patient had pain in the left foot. The patient was taken to St. Joseph's Hospital in Wayne. In the ER he was diagnosed with gout and begun on Colchicine. Since that time he has shown no improvement. He has become essentially chair-bound and unable to walk so he is brought to St. Joe's ER. His medical history is significant for atrial fibrillation, hypertension, hyperlipidemia, coronary artery disease and the patient also has a colostomy bag he had a procedure done and they were unable to connect is

2. Also recommend getting dermatology referral to assess the lesion on his right forearm which has been nonhealing and indurated margins, is suspicious of malignancy or sarcoidosis

At today's visit he is awake, alert and oriented. He complains of generalized pain. He states “I have pain all over today, my head, my back, my feet" I have not felt good for the last few days”. He rates his pain as 6/10 in severity; he describes his pain as shooting pain in different places. His pain does

E.P. is an 88-year-old Caucasian male. He was admitted on 02/18/13. His code status is full code, and he declines to bring in his advanced directive. He reports that he is 68.5” tall, and his actual weight is 165 pounds. He and his wife are the sources of information, and they are reliable. His blood pressure is 124/62, taken on his right arm in a lying position, his oral temperature is 99.8, his right radial pulse is 74 beats per minute, his respiration rate is 16 breaths per minute and his pulse oximetry reading is 92 on room air. He is allergic to latex, cephalexin and sulfa drugs, with a reaction of hives, and to IV dye, with a reaction of moderate rash. He was

I.We have reason to believe that the system that is being attacked in Sam is his lymphatic system. There are many signs that point to this conclusion with the most strong point being his edema on his right leg. This Edema, or abnormal accumulation of fluid, is believed to have been caused by a compromised amount of function in the lymphatic system. This system’s primary function is to pick up and return leaked fluid from blood vessels. When this system can not function properly it could result in an edema and pain, both of which are being experienced by our patient. The next point that leads us to believe the lymphatic system is being attacked is the fact that there are signs of bacterial infections. The lymphatic system also plays an immunal role in helping the body function, and if it couldn’t produce the white blood cells needed to fight infections, bacteria could potentially take over, which could be the case with Samuel.

Resident has significant loss of function of the left shoulder and right knee. Rest of the joints and muscle groups are within the functional limits. Right knee fixed flexion deformity (approximately 35 degrees), left shoulder AROM limited to 20 degrees in all direction. Resident has good sitting balance. Able to stand up at the rail/with 4WW with two assists at the rail. His standing balance is very poor. Resident is at

The patient is a 75-year-old gentleman who presents to the ED brought in by wheelchair with complaints of falls and injuries. H he presents also with pain it's chronic it radiates down his left leg symptoms became worse over the past 5 days is also consult related having weakness neck pain in his medical history is significant for enlarged prostate hypertension good cancer carcinoma of the neck and liver carcinoma patient also does some indication that he had a liver transplant 14 years ago on a CT brain done in the ED revealed him to be highly suspicious for normal pressure hydrocephalus number of the lumbosacral was noted to have mass in the sacral area highly suspicious for metastatic cancer is also known to have cervical myelopathy in

The patient has a supportive neighbor who drove him home from the hospital and a senior services volunteer who drives him to the nursing home his son resides at. Strength in his right UE is 4/5 in shoulder movements, 3+/5 in elbow and hand, and 3-/5 in his wrist. He has edema in his wrist and fingers along with pain in most wrist movements. AROM in his elbow is a -25 degrees extension, wrist has 20 degrees of flexion and 15 degrees of extension, and his fingers are -1/3 of full ROM. The patient is right handed and also has impaired coordination during fine-motor and dexterity movements with his right UE but is left UE is WFL. The patient has a positive prognosis with nursing and occupational therapy interventions to return to a functional level of

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.

At today's visit he is accompanied by his wife. He is awake, alert and oriented times 3. He reports that he was started on Augmentin antibiotic for respiratory infection 2 days ago. He states that he has a cough that started a week ago, the cough is nonproductive, the cough is worse at night, he states that the coughing increases his pain. He states that he has not tried any medication for the cough but would like some thing. He complains of , chronic, nagging,