PMH

Active problems: Right foot amputation, chronic pain, PTSD, anxiety

Inactive problems: None

Hospitalizations: Extended hospitalization for management of right foot crush injury requiring subsequent amputation

Immunizations: up to date tetanus shot (5 years ago). He never got any of the COVID 19 vaccines

PSH

Symes amputation right foot

Allergies

Sulfa

Medications

Amitriptyline 25mg one tablet by mouth every evening (patient is not taking because " it does nothing for his pain

SH

Substances: +Tobacco, 1 ppd, ETOH 2 drinks daily (whiskey on the rocks), marajuana nightly

Diet: fast food, junk food. 

Exercise: no formal exercise, works on her feet 8 hours a day

Sexual activity: monogamous, not been active for the past 4-5 months. His wife just had their 3rd child by C-section and is recovering 

Home life: Married to Simone, 3 children; 5 years old daughter, 3 year old son and son 6 weeks old (born at 32 weeks)

Occupation: Grocery store worker

Context: Live in a small town, Malta, OH. High level of stress due to intractable pain, insomnia, physically demanding job and financial difficulties.

FH

Mother: (deceased) age 57 y/o ovarian cancer, dementia

F: (living) age 69 y/o , HTN, hyperlipidemia, AUD, depression

B: (living) age 35 y/o HIV

Review EHR by using the navigation panel on left side of screen. View Simone's video once chart review complete.