He is total care with his ADLS, he is able to verbalized his needs but unable to perform them. He reports that he had a colostomy placed in 2011 and urostomy placed in 2014. His father provides hygiene care and changes for both his colostomy and urostomy bag. He has bilateral arm/hand contractures and he has gotten weaker. He is getting OT and PT from kindred home health. He uses a hospital bed with air mattress and his father changes his position every 3 hours. He reports pain in his legs and back that is constant, dull and aching. His pain is worse with movement and dressing change. His current pain level is 8/10 on a pain scale. His pain regimen consists of fentanyl 75 mcg patch every 72 hours and oxycodone 5 mg p.o every 6 hours as needed for breakthrough pain. He has been taking 2 prn doses daily because he did not want to run out of medication. He states that 2 prn dose is not effective in relieving his breakthrough pain. He previously was getting his medication from his PCP but since his condition has deteriorated his parent who are elderly is not able to get him to the
In addition, CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. As noted above, this is an appeal to the previously denied request on 02/09/16. The appeal letter states that the patient has low back pain. MRI report showed disc bulge at L5-S1 with left neural foramina narrowing. However, 01/06/16 progress report noted that there was no radiculopathy with a negative SLR on exam. The guidelines require documentation of radiculopathy on exam. In addition, there is no documentation of a trial or failure of conservative treatment, including PT, as recommended by the guidelines. Furthermore, there is no documentation of any focal neurological deficits on the exam that would indicate nerve pathology. The motor and sensory exam was normal. Medical necessity has not been established. Recommend
On 5/30/18 I met Mr. Reid at the office of Dr. Rampersaud. I explained that the insurance carrier is not getting the form filled out correctly regarding his narcotic medications. I asked his permission to meet with Dr. Rampersaud when they go back to the examination room and leave once we discussed the form. Mr. Reid agreed. He reports that since having the spinal cord stimulator battery replaced his pain is 60% better. He reports his pain level is a 6. He continues to have his legs give out unexpectable. He reports needing help from his wife to roll him over when he is in bed. He continues to use a wheelchair. Mr. Reid said he wanted to speak with Dr. Rampersaud regarding decreasing his medications at least for the summer. He feels the warm weather makes his pain more tolerable.
On 1/16/17 I met Mr. Anderson at the office of Dr. Rampersaud. Mr. Anderson drove to the appointment. He uses 2 canes to walk. He reports that he and his wife drove to Florida on 1/4/17 to 1/15/17. He said they walked everyday while he was there. He reports his pain is a 9. The pain is in the left Si and caudal along with the low back. Mr. Anderson is scheduled for several injections today after we meet with Dr. Rampersaud. Mr. Anderson’s current medications were discussed. I remind Dr. Rampersaud that we are on a tapering process with the medications. Mr. Anderson was instructed to decrease the Dilaudid to 3 times per day from 4; the
Patient was encouraged to continue with heat, followed by his home exercise program and ice. He will continue with his transcutaneous electrical nerve unit (TENS). Patient was given an ice pack to use, to reduce pain. He was given a 60 mg Toradol injection on this visit.
Based on the latest medical report dated 04/08/16, the patient presents for follow-up of his lower back pain. He is status post radiofrequency facet on the left that initially helped with left sided lower back to 60%. He stated that PT was stopped by insurance for the past 2 weeks. Since he started PT, he has been having increased spasm across his lower back with pain into the left lower extremity. IW feels that PT
The patient has a history of discectomy to the left with temporary improvement of his lumbar pain and lower extremity symptoms. He has reherniation to the left correlating to the L4-L5. He has had transforaminal epidural steroid injections and facet injections with relief of his lumbar pain.
The purpose of this paper is to analyze information on a pregnant patient. The information will be compared to the expected normal patterns of a healthy pregnancy. Risk factors will then be looked at for implications and recommendations for ways to improve health of the patient. Finally, teaching and anticipatory guidance for this specific patient will be given.
12/31/15 Progress Report described that the patient has cervical spine, right shoulder, and right wrist pain. She rates her cervical spine at 8/10-scale level and frequent; right shoulder pain at 8/10-scale level; and bilateral wrist pain at 6/10-scale level. The pain is frequent and improved since last visit. Rest and medications make the pain better. Weather
11/25/15 Progress Report described that the patient has moderate to severe pain in his lumbar spine. The pain is 5-6/10-scale level. It is radiating, to his right leg; associated with stabbing; aching and sharp. There is limited ROM due to pain, with stooping, bending, lifting, pushing, pulling, carrying, walking, standing, sitting, ascending and descending stairs. The patient reported difficulties performing his ADL. The patient also reported sleeping problems. The patient is not working since is injury. The patient is currently taking Advil 200 mg an ibuprofen. Exam of the lumbar spine revealed tenderness to palpation over the
Objective Functional Improvement shows that the patient is now able to get dressed with minimum assist. He is also now able to navigate 2 flights of stairs without pain, same as prior, now able to walk for 8 minutes, same as prior, can now lift 6.5 lbs. of weight, improved from prior, and push 6 lbs. of weight, same as prior. Therapy goals for this patient in the next 4 weeks are to reduce inflammation from moderate to minimal and increase cervical and lumbar spine flexion and bilateral rotation by 3 degrees. The patient in the next 4 weeks will be able to get dressed easier, navigate 2.5 flights of stairs without pain, walk 9 minutes from 8 minutes, lift 7 lbs. of weight, and push 7 lbs. of
Physical examination revealed that the patient’s back is less tender. There is facet tenderness over the bilateral L3-S1. There is also slight pain with limited rotation, flexion, and hyperextension. The right lower extremity is noted to be weaker. The lumbar spine examination is positive for seated straight-leg raise on the left and facet loading. As per treatment plan, the patient will be continuously evaluated for medication regimen and make alterations as necessary. It was noted that the patient states that there is continued need for his Zanaflex as necessary for flare-up of muscle spasms until he is able to start up chiropractor therapy again. He will try to discontinue the medication next month with chiropractor therapy. As per office notes dated 5/23/16, the patient’s pain level is 5-6/10. He states continued need for his Zanaflex as necessary for fare-up until he is able to start up chiropractic therapy. He continues to have neck pain with intermittent periods of sharp-stabbing pain over the right side with radiation to the bilateral upper extremities with numbness as well as associated cramping into upper extremity and into fingers. Current medications include Zanaflex, Nexium, Celebrex, and
Based on the progress report dated 04/05/16 by Dr. Fieser, the patient complains of pain in the left knee, left ankle and left foot, associated with numbness and tingling in the left leg/foot, as well as weakness in the left leg. He describes the pain as sharp, cutting, throbbing, dull, aching, pressure-like, cramping, shooting and shocking with muscle pain and pins-and-needles sensation.
02/09/16 Progress Report noted that the patient’s current medication regimen provides moderate pain relief without any adverse effects. The patient stated that he has seen Dr. Smith for IT pump clearance and would like to proceed with the trial. He has chronic lumbar back pain. The pain radiates the left buttock, left posterior thigh, left lateral thigh, left lower leg, left foot, and right lateral thigh. The patient describes the pain as sharp, dull, aching, bumping, stinging, and throbbing. The onset was sudden immediately after the injury. The symptoms are constant and the episodes occur daily. The symptoms are described as severe and worsening. Back motion, lifting, and bending exacerbate the symptoms. Associated symptoms include leg numbness, foot numbness, leg weakness, and foot weakness. Current treatment includes opioid