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.
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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
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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
He was given a prescription for Fexmid (cyclobenzaprine hydrochloride) 7.6 mg #90 1 tablet every 8 hours as needed to reduce muscle spasms, Voltaren XR (diclofenac sodium XR) 100 mg 1 tablet #60 1 tablet twice daily as needed for inflammation, and topical creams.
Current medications include Norco 10/325 mg 1 tablet every 6-8 hours as needed for pain, Naprosyn 500 mg 1 tablet twice daily and Prilosec 20 mg 1 capsule daily.
DOI: 12/23/2013. The patient is a 64-year-old male foreman who sustained injury when he was involved in a motor vehicular accident. Per OMNI, he has had multiple injuries to the right shoulder, right knee, back and right arm/elbow. He is status post arthroscopic surgery for the right shoulder on 05/30/2014.
DOI: 10/14/2009. Patient is a 44-year-old female hospital medical records clerk who sustained a work-related injury after tripping over a garbage can and fell on her right knee.
At today's visit, she is awake, alert and oriented times 3. . She complains of back pain that radiates to her abdomen and down her legs. She describes the pain as deep ache that is aggravated with movements with a severity of 8/10. She states that her pain has worsened and that her current pain regimen is not effective. She states she has been taking her Dilaudid every 4 hours. She stated that she had fentanyl 50 mcg patches from what she uses to take previously. She states that she used her 50mcg patch and her pain had
DOI: 7/18/1999. Patient is a 63-year-old male crew leader who sustained a work-related injury when he tripped over a mat at work. As per OMNI, the patient is status post left knee arthroscopy in 2001, knee replacement in 2004 and gastric bypass surgery in 5/2013.
This is a 48-year-old male with a 6/7/1995 date of injury. A specific mechanism of injury has not been described.
The most current medication regimen included Cyclobenzaprine and Acetaminophen. Her past medical history was significant for pre-diabetes, hypertension, and high cholesterol.
IW will follow up in one month. Patient will receive a written prescription for Soma 350mg 1 tablet three times daily #90, Morphine extended release 60mg 1 tablet twice daily #60 and Norco 10/325mg 1 tablet 5x a day as needed for breakthrough pain #150.
The numbness has increased. She is now experiencing numbness in the pelvic floor and bilateral anterior thighs. She complains of weakness in her right leg. She has difficulty with walking and standing. She has been experiencing bowel and bladder incontinence.
DOI: 2/10/2016. Patient is a 51-year-old female housekeeper who sustained left knee injury when another employee from the hotel accidentally hit her knee with the housekeeping cart. As per OMNI, she was initially diagnosed with tear in left knee. He is status post left knee arthroscopy on 6/23/2016.
MD has been reducing his spinal infusion pump. He is doing well with the reductions. He has received his new walker and a power wheelchair. He uses medical marijuana for anxiety. CURES report was checked on 02/18/16 which revealed
DOI: 4/12/2014. Patient is a 53-year-old female sales advisor who sustained injuries to her right shoulder/upper extremity, thoracic spine and lower back when she lost balance and fell while pulling a cooler away from cart.
DOI: 03/23/2015. Patient is a 34-year-old female cleaner who sustained injuries to her left knee and left elbow while she was walking through the lobby and tripped over her own feet falling onto the cart and marble floor. She is status post left knee partial lateral meniscectomy on 08/04/2015 and second left knee surgery on 09/27/16.
DOI: 5/1/2012. Patient is a 39-yearold female packer who sustained injury to her head, back, right shoulder and right leg when boxes fell on her.