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Cancer Case Studies

Satisfactory Essays

DOI: 10/14/2009. Patient is a 44-year-old female hospital medical records clerk who sustained a work-related injury after tripping over garbage can and fell on her right knee on 02/07/2010.
Per office visit notes dated 12/10/2015, the patient’s current medications are Cymbalta 60 mg, Ultram ER 200 mg, Doxepin 3.3% cream, Gabapentin 600 mg, Ketamine HCL 5% cream, and phendimetrazine 35 mg.
Based on the visit note dated 01/08/16, the patient presents for a follow up visit. She is status post right L4-5 and L5-S1 radiofrequency ablation performed on 9/30/15 with 10-12% relief. She notes her pain is back to baseline.
She reports that she continues to have pain and swelling in her right knee but is also now getting swelling in the left side. …show more content…

She also had PT for the right knee which has not helped.
Examination of the lumbar spine reveals loss of normal lordosis with straightening. Range of motion is restricted. Lumbar movements are painful with flexion beyond 50 degrees and extension beyond 10 degrees.
Spasm, tenderness and tight muscle band is noted on both the sides of the paravertebral muscles. Wadell’s sign and Pelvic compression test is positive. There is spasm over the right sacroiliac joint and right L5-S1 and L4-5 facet joints. Kemp’s maneuver is positive bilaterally, right greater than the left. Right provocative facet maneuvers are …show more content…

Diagnoses are lumbosacral region intervertebral disc displacement, intervertebral disc displacement, lumbosacral radiculopathy and sacroiliitis.
The IW notes that her current dosages are not working. She does find Cymbalta beneficial with her anxiety and depression but not much improvement with gabapentin and Ultram ER. She has trialed several other opiates in the past at much higher dosages and she would like to trial them again for pain control.
MD will not continue to escalate her pain medications. IW was advised going on a drug holiday but she defers it for now. She states that Ultram ER is helping her some and would like to continue it at this time. Ultram will be gradually increased from 50mg 1 tablet twice daily to 200mg 1 tablet daily. MD will no longer continue escalate dosages.
She was given a prescription for Cymbalta for pain, anxiety and chronic musculoskleteal pain and Ultram for around the clock pain relief. Neurontin was dispensed.
She will follow up in 4-5

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