Unrestrained passenger in a MVA, Her car was rear ended and she was thrown forward.
Listed as Affective/Mood Disorders & Anxiety Disorders at Onset
SSI & SSD
She is still working, but get clarification on last date worked full time.
RFC assessed at all exertional levels, with non-exertional restrictions including limitation to unskilled work
Reported shortness of breath
Notes: Complained of SOB for 2 years, associated with cough and clear phlem. Shortness of breath with minimal exertion.
Assessment: Sarcoidosis, clinical stage 2, biopsy proven
Plan: Start prednisone 30mg, renal evaluation for kidney, pulmonary testing and CT of chest 3-6 months.
Prognosis- May need lifelong anticoagulations due to positive factor V Leiden
Daughter thought she would hurt herself following suicide of fiance. She did have suicidal ideation.
DX: Major Depressive DO, Severe, Recurrent; Generalized Anxiety DO.
GAF on Admission= 10, on Discharge= 50
Depressed, no sleep, no appetite, mild paranoia, pressured speech,
DX: Major Depressive DO, Anxiety DO, R/O Borderline personality DO GAF 55
MRI of Left Shoulder: Mild acromioclavicular osteoarthritis
Mild disc desiccation at T9-10
Impression: L4-5: Traverse and AP spinal stenosis with associated disc dessication and disc bulge causing ventral thecal sac, lateral recess enchroachment
Impression: Muscle Spasms
Offers Dx, notes positive ortho testing, orders EMG,
For complaints of persistent lower back pain which radiates into the lower extremities with tingling and numbness in the feet and the toes.