Knee Contusion Visit

On 8/25/2015 S/O EMT Perez was dispatched to PV-509 regarding severe leg pain. S/O EMT Perez knocked and announced his presence at the door and was verbally invited in by the resident a Mrs. Margaret Folkins. Mrs. Folkins stated that she had been in severe leg pain the entire day and she was having difficulty resting. Mrs. Folkins also stated that she was at the hospital for it the day prior because of it but the cause of the pain couldn’t be diagnosed. S/O EMT Perez asked Mrs. Folkins if she had fallen recently and if that was the reason for her visit to the hospital prior. Mrs. Folkins stated that she fall’s all the time but that wasn’t the reason for her visit to the hospital yesterday. The reason for Mrs. Folkins visit to the hospital yesterday

Kathy has a weight bearing restriction in place, is currently utilizing a wheelchair for mobility, and is a hands on one person assist with transfers. Judy shares that the previous day Kathy and the physical therapist worked with Joe and herself on transfers into and from the car so they can take her to her scheduled appointment with the orthopedic doctor on Friday. Judy shares that it is expected that the doctor will modify the weight restriction at the appointment. Judy and SSA spoke about a time frame for discharge. Judy shares there is no time frame established. Per Judy, Kathy’s private insurance only has twenty days of physical therapy remaining in the plan and does not know what happens at the end of the twenty days if Kathy needs additional therapy. She has plans to contact Humana later this day to discuss Kathy’s insurance benefits. We discussed that Kathy believes she has an UTI and that a sample of her urine was taken before lunch for testing. We discussed that Kathy is satisfied with the Care Springs facility, the food served, and nurses assigned to work with her. During the visit, Kathy asked about Wildey staff and of all who was aware of her injury. We discussed her

displayed signs of a suspected left hip fracture. Clinical indications would most likely show that the leg is held in external rotation and abduction, and appeared shortened when the patient lay in the supine position (LeBlanc et al., 2014). The patient would be in a high degree of pain and discomfort. Due to her care responsibilities, Mrs B. is keen to return home, and may be concerned about her ability to provide the same level of care after her injury. Where uncooperativeness and non-compliance with the requests of the nursing staff results, Milne, 2018, advises that patient cooperation relies on patience and good interprofessional communication.

Patient was here with cousins to be seen. This occurred at end of the visit approximately 1:15 pm. I was called by Madelyn Ramirez (PCT) that there was an incident in the exam room. I spoke to the mother, she said he was fine that he did not hit his head. No injuries noted, mother decline being evaluate by provider. But, patient was evaluated by Dr. Ritchin after fall.

R.P. is a 74-year-old married Caucasian female that is a homemaker that lives at home with her husband. Reason for her care is due to a recent fractured left hip and left wrist. She stated that she slipped on a rug in her home and landed on her left side. R.P. reports pain being 10/10 and sharp and radiates all over body stating, “even the slightest touch of skin hurts so much”. It all began a few minutes after the fall. Pain is alleviated with narcotics (hydromorphone and morphine) and immobilization.

On 4/6/2016, CM met with the client to complete Bi-Weekly ILP Review. In the meeting client was dressed in a brown jacket and beige pants and black sneaker. She was wearing reading glasses. During the session client reported she wasn’t feeling well she have a strep throat for the past 8 days. She reports coughing, fever and sore throat.CM inquires if the client met with the on-site medical staff client replies “No”. CM advises the client to see on-site medical staff. Client in the meeting was repeating the same things over and over.

12/24/15 Progress Report describes that the patient has right knee pain. The pain is frequent. It is aching and burning in quality. The current pain level is 0/10 and worst pain is 4/10. Bending, squatting, walking, weight bearing, changing clothes and ROM aggravate the pain. Rest, ice,

On 8/8/2016, CM met with the client to complete Bi-Weekly ILP Review. Client appears to be alert, cooperative and friendly. She was dressed appropriately for the weather. CM inquires how the client has being doing since the last Bi-Weekly ILP Review. Client replies “ok”. CM inquires if the client is more active in participating in onsite recreation activities. Client replies; she is able to participate in some and not all due her psoriatic arthritis.

CM was out on vacation for the period of 5/2/2016 to 5/9/2016. On 5/19/2016, CM met with the client to update Assessment and to complete Other ILP Review. In the meeting client appears to be friendly and cooperative. She appears to have some cognitive impairment. Client reported WECARE/Wellness referred the client to see Dr. Larissa Lempert/Neurology. Next upcoming appointment is scheduled for 5/26/2016. During the meeting session, client was dressed appropriately for the weather and had good hygiene. She ambulates with a cane due to leg problem. Client affect was flat. Client denied suicidal or homicidal ideation.

The evidence in file shows the claimant has a history of back, shoulder and leg pain. He was seen 4/11/17 in the emergency room. He complained of back pain. His gait and the rest of the physical exam was grossly was normal At the internal medicine consultative exam (IMCE) on

RT had a scheduled medication management appointment with Mary Pestrak at 4:30pm on 6/15/16, but RT called NP Mary and rescheduled. RT stated that she wouldn't be able to come to TSI for her appointment. However, writer met with RT and inquired about RT's well-being and RT stated " I am doing good". RT informed writer that on 6/14/16, she went to her PCP and did blood work and is scheduled to go back to her PCP on 6/21/16 to get the completed physical form hat was provided to RT by writer. RT's medication management appointment is rescheduled for 6/22/16, RT ensured writer that she will be there. Writer informed RT that she is awaiting to hear from Marguerite to get more information on a GED program. RT was appreciative of writer's assistance.

In Kindred Rehabilitation, the patient had a total knee replacement due to osteoarthritis. Osteoarthritis causes degenerative changes, within the joints causing bone stiffening and reactive inflammation. My patient was admitted on 10/21/11 with osteoarthritis and a left total knee replacement. Her PT and INR were a concern because she had developed mild thrombocytopenia which resulted in the elevation and potential bleeding. The physician had to take her off of Lovenox and switch her to an oral anti-coagulant Xarelto at 10mg once daily. During her care I was educated by the interdisciplinary teams managing mobility, safety, and the more

| Admission Diagnosis: Left Total Knee Arthroplasty &Excision of Left Knee Mass Related to Gouty Arthritis

A torn ACL is one of the most serious and common knee injuries. Many aspects play a role in the treatment and rehabilitation of this injury. This paper will discuss the anatomy of the knee, describe a torn ACL, and the rehabilitation.

This reporting period, Mrs. Hare continues to have good and bad days regarding her lower extremity pain. She rated her discomfort ranging from a “7-10”. Mrs. Hare did have to take a pain pill once a week which reduced her pain to a “2”. Ms. Hare has not returned to therapy or obtained her orthotics but she is returning to acupuncture. Mrs. Hare has obtained her dental records and is in the process of locating the Dentist that was referred by a family member. I once again reminded her of the social security