Primary care physician report

Primary Care Physician Report
Edward Vanelli, MD
June 9, 2005

Victor Gomez has been under my care for approximately seven years. In February of
2003, Mr. Gomez was involved in a work-related accident that resulted in severe burns
over 65-70% of his body. He was hospitalized initially at University Hospitals in
Phoenix then underwent rehabilitation at Payson Regional Medical Center. He was
discharged to his parents’ home where he continues to live. He has not been able to
return to work since the accident.
Upon discharge, Mr. Gomez received services from a home healthcare registered nurse
three times per week in order to monitor his burn wounds. He also attended physical
therapy three times per week and followed a home exercise program that involved using
pulleys for strengthening, walking and swimming in a neighborhood pool. He eventually
regained the ability to walk without a walker. Pressure garments were worn on both
hands to decrease scarring. His occupational therapist reported slow progress with his
range of motion decreased because of contractures. Dynamic splinting was needed on
both upper extremities and a surgical procedure was eventually needed to release the left
wrist/elbow contracture and the left axilla skin overgrowth. Formal therapy was
discontinued in March of 2004 because Mr. Gomez reached a plateau in all areas. It was
felt that he could progress into a fitness program and continue with home exercises.
Mr. Gomez returned in January of 2005 because he was experienced increased left leg and ankle pain as a result of skin grafting. He was placed on Neurotin 300 mg. Three times per day which helped with pain control. He continues to use Darvocet and Vicodin as needed. He requires some amount of pain medication daily. Mr. Gomez also continues to take Prevacid as prescribed for increased stomach acid production and to prevent the development of ulcers. He also takes Zoloft (50 mg/day) for treatment of depression and anxiety and one multivitamin daily for nutritional supplementation. Mr. Gomez ‘s weight has improved and is nearly at pre-accident level. Current issues include: 1. control of pain resulting from extreme scarring on the upper and lower extremities. This pain is neuropathic in origin and is treated with Neurotin and narcotic pain medications as needed. These remedies appear to be working fairly well at this time. 2. Weak left hand grip due to a contracture. Mr. Gomez is doing exercises taught to him during rehabilitation but may require additional surgery to release the contracture. 3. Depression and anxiety as a result of severe burns. Treatment consists of Zoloft which is controlling symptoms well. Mr. Gomez also has sleep disorders associated with depression and anxiety. 4. Increased production of gastric acid and the potential for creation of a gastric or duodenal ulcer. This is a common occurance during burn recovery. Mr. Gomez is taking Prevacid to prevent this from occurring.

Source: http://learn.niu.edu/COMD492/Resources/Primary_Care_Physician_report.pdf