Case Study Pateint

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DOI: 6/12/2014. Patient is a 59-year-old right-handed male machine operator who sustained work-related injuries to his right arm, shoulder and neck when his right hand got caught in a mixer. As per office notes dated 9/6/16, the patient returns complains of continued neck pain with burning hot pain extending into the forearm down to the hand along the C6 and C7 distribution with numbness and tingling in the hand. The patient has undergone multiple medications, physical therapy, TEN both in physical therapy and home use. It was also noted that the pateint denies having cognitive behavioral therapy. The provider notes, that it would be appropriate as based on the history including postoperative right forearm fracture repair and forearm open reduction and internal fixation of the right distal radius that an additional surgery to the right arm and continue physical therapy, yet continues to have swelling…show more content…
The provider further notes that he belive that it is appropriate to have the pateint taught techniques and nonpharmacological implementation of pain control. If the pateint is not able to undergo this treatment, the patient would certainly be a candidate for “PENS” treatment for the neuropathic pain in the upper extremity. He has undergone multiple therapies and injection and still continues to have the burning sensation.
It was noted that the random urinary drug screen dated 6/14/16 (no official report) is consistent with medications. Controlled Substance Utilization Review and Evaluation System (CURES) dated 8/1/16 from department of Justice (no official report) found to be consistent with the medications. The pateint also has opioid agreement signed 7/14/16 and a grade of 3 on opioid risk assessment. The 4 A’s of opioid monitoring notes that Norco and Neurontin notes that were not prescribed in the past and do not have significant documentation to provide functional improvement.
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