Mrs. Port Case Summary

May 18th 2014 Mr. Beaird fell and broke his hip. This followed hip surgery performed by Dr. Baker and 21 day rehabilitation form Cordova NH. Before his 21 days was up Mr. Beaird tried to break out of NH by running his scooter though the front door at the NH. When the scooter hit the door, the door opened and Mr. Beaird rolled onto the front porch during this altercation, his foot was injured and the ambulance was called. Mr. Beaird was admitted to Senior Care and diagnosed with a

Client continues to reports she suffers from, hypertension, Dyslipidemia, Psoriasis, H/O stroke, chest pain. She takes the following medications: Lisinopril 5mg, and Hydrocortisone Cream

She converses appropriately. Blood pressure 92/60 supine. Blood pressure decreased to 72/50 standing. Pulse is 90 and regular. Weight 113 pounds. She has a normal appearance of her face and does not have a masked appearance of her face. She has good strength throughout her face. She has good strength of her extremities. She has only minimal cogwheel rigidity at the left wrist, but no cogwheel rigidity at the right wrist. She has no tremor of her hands. She moves her extremities freely and with normal speed. She is able to rise on her own from a sitting to a standing position, only minimal bradykinesia of standing. She walks fairly freely and there is a normal cadence of her gait. She did not have dyskinetic movements of her extremities. She is able to walk, including turning without losing her balance. She does not shuffle her feet when walking. She does not have en bloc turning. She has good posture stability

Per the medical report dated 07/18/16, patient is being seen for her lower backache, rated 7/10 with medications and 10/10 without medications. Current medications include Ambien 10mg; Maxalt-MLT 10mg; Norco 10/325mg; Evzio 0.4mg; orphenadrine 100 mg and gabapentin 600 mg.

pressure). She fell upon entering the bathtub when her right leg slipped out from under her; she

At today’s visit she is found sitting in the chair, she is awake, alert, and confused. I am asked to seek this pain for new onset pain. The patient complains of acute pain in pubic area and right hip area, pain is dull, achy, severity 4/10, pain is worse with walking. At this time the patient is not taking anything for pain. The ALF staff reports that the patient has daily anxiety and has to be given Ativan three times daily. The patient ambulates with a walker. Gait is

Medical Diagnosis: Client was diagnosed with a fractured right tibia bone, and fractured right radial bone. Client has diabetes mellitus type one. Client has history of hypertension and was admitted with chest pain following accident. The client fell off her bicycle while walking her dog.

She reports a history of back pain, ovarian cysts excision, and breast tumor. She denies chest pain, shortness of breath, or palpitations. Patient reports that her immunizations and preventive care are up to

She will need a wheelchair to be mobile to care for herself. She complains of pain in left thigh that radiates down her leg. She describes the pain as a “deep, deep sharp pain that is sometimes dull and burning, it is a 15-20/10 in severity on a pain scale”. She also has lymphedema to left leg from her toes up to her groin that she states has been progressively getting worse. She gets weekly lymphedema therapy from healthy lymphatic home agency and is schedule to follow up with the Mayo Clinic on 9/29/16. Her pain regimen is fentanyl patch 75 mcg topically every 48 hours and Dilaudid 4 mg, 2 tablets every 4 hours. She has had 6 as needed doses of Dilaudid 4 mg, 2 tablets (8mg) in the last 24 hours. Her pain had not improved it remain a 15-20/10 on pain scale. She states that in the past she took gabapentin 100 mg p.o three times daily but it did

The nurse will assist Mrs. Thomas in achieving optimal pain control. The nurse will interact with Mrs. Thomas more than any other practitioner. The nurse will have to continuously assess Mrs. Thomas pain control. Due to Mrs. Thomas’s advance stage in her illness her pain control needs will vary depending on her level of conscious and the disease process. Keeping Mrs. Thomas’s level of pain to a level where Mrs. Thomas can still maintain her functional ability will be an ongoing struggle. Too little or too much pain medicine will prevent Mrs. Thomas in participating in activities.

M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems.

At today's visit she is home alone. She is awake and alert. She complains of burning, Shooting pain in right Buttocks and hip area that radiates down her leg. Severity 10 out of 10, she currently takes OxyContin 40 mg every 12 hours and Percocet 10/325 every four hours as needed. She states that her pain is very debilitating and prevents her from leaving the house. She ambulate's short distances with a walker but has to take frequent rest periods.She states that this pain regimen is not helping much. She was going to resolute for outpatient pain management but at the moment she's unable to get out to her appointments due to her sciatica pain. She complains of chronic constipation.

Based on the medical report dated 10/27/16, the patient rates her pain with medications as 4/10. Her activity level has increased.

Review of the medical record indicates that she was admitted to the hospital on 8/12/16 with complaints of intermittent headaches, low back pain and weight loss. She has previously been diagnosed with metastatic cancer involving the lungs, bone, brain, and liver and started to undergo radiation therapy but has not yet undergone any chemotherapy. She has had 10 radiation treatments with Dr Castello who is her radiation oncologist.

A review of her medical records indicates that she went to the ER on 12/4/16 with complaints of back pain as a result of her fall she had 2 days prior. She was prescribed Norco 5/325 mg p.o every 4 hours prn. She has an extensive history of falling at home due to her Parkinson disease which is progressive. She suffers from Parkinson with resulting tremors. She is receiving physical therapy from signature home health. She suffers from co-morbidities of chronic HTN, which is managed with medication, CAD which is stable, Chronic hypotension which is managed with medication, depression which is stable.