Controlled on provastatin40 mg daily dt is a 23 years

  • Walden University
  • NURS 6565
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D.T is a 23 years old man observed with dry rashes around his elbow, eyesocket, and around his joints. Alert and oriented and petite in size. Lungs areclear and positive bowel sounds. No edema on lower extremities. Mucousmembrane moist and no lesion noted in his mouth. The patient was orderedmedication for his eczema and refills of his other medication. Pt was born with aheart defect called tetralogy Fallot, I always get very tired and my extremitiesturned blue after exercising. I am allergic to my own sweat and it causes rashesaround my joints and around my eye. I get cold faster and my appetite is poor."P.P is a 54 year old female with PMH of Fibromyalgia , Depression, HTN camefor follow up after ER visit last night following a an exacerbation of Pain on theleft lower extremitis. She rated pain as high, reports she was managed with painmeds and muscle relaxant. Per patient diagnosis of left Trochanteric bursitis wasmade during previous ER visit. She ambulates with a cane for support and canonly bear 50% of her weight on the left side. She is emotional about frequentflare up of the fibromyalgia pain despite being compliant with her meds. Shecomplains that this affect the quality of life and work for her, she is afraid of losingher job. Refill fentanyl patch for fibromyalgia pain relief, left hip bursitisInterventions admin ketoroloac for acute hip pain, gait trained with crutches, pt is scheduled to see orthopedic later this month, will follow up with pt afterconsult.Mr. D.A. is a 25 year old AA male with no significant PMH who presents today foran annual physical. He reports that he is in good health, and has no physicalcomplaints at this time. He has a form that he needs us to complete in order forhim to get married. Patient is in good mental and physical health. Patient hadannual labs drawn today. He return in 1 week for results review. Pt receivedinfluenza vaccination today.
Pt is a 61-year-old AAF who was seen to establish care. She is complaining offungal nail infection that started initially as pain with yellow discoloration to theleft thumb and 4th finger about 2 months ago, no pain resolved but toe nail dark.No other complain was reported. Microcrystalline 500 mg tablet; 1 PO q12h; simvastatin 10 mg tablet; 1 PO qd; Dispense: 90 Tablet(s); Synthroid 1 PO qd; captopril 12.5 mg tablet; 1 PO qd; DispenseM.D is a 28 yo Hispanic female with a PMH of asthma who presents for follow upregarding an MVA. She has been seen here multiple times for this complaints,but is currently here to review recent lumbar x ray that she had performed. Shereports continued lower back pain with intermittent radiation down bilateral legswith numbness and tingling, left greater than right. She also endorses intermittentleft leg weakness. She denies any bowel/bladder incontinence or genital orpersonal numbness/tingling. She has attended 6 physical therapy sessions andhas two left and feels they are helping. Patient in physical therapy and she cancontinue. Given metaxalone for use as needed for muscle spasms. Seen on

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