Dr. Rampersaud Case Study

On 11/23/16 I met Mr. Westover and his daughter Jackie Syms. Mr. Westover has made good progress with the continued physical therapy. He has resumed driving locally. Mr. Westover reported he had been in the hospital for 5 days recently for pneumonia. He is not using his cane now unless it is slick outside. He reports still feeling weak in the left leg. The Neurontin did work but Mr. Westover reported he stopped taking it and feels fine. Per Ms. Syms Mr. Westover’s PCP has him taking the blood thinner again. Mr. Westover agreed to take it until January 2017. Mr. Westover asked to have his home physical therapy continue, he doesn’t want to drive on winter roads. The last update from therapy asked for 3 more weeks and then they would

He underwent an interlaminar injection in May 2015 which improved his lower extremity pain by 99%. This has lasted him up until 1 month when he has had recrudescences of pain emanating from the low back radiating intermittently into the left lower extremity in a sharp shooting fashion, average pain 5/10, and worse pain 81/0. The pain is frequent and is associated with numbness and tingling. There is some difficulty with walking. Over the past 1 month, the pain has been severe. Home exercises and nonsteroidal anti-inflammatory medications (NSAIDS) have not been effective in reducing his pain and the pain is severe at times and limiting his ability to lift and sit. Walking, exercise and standing increased the pain. Lying down reduce the

Review of the medical record indicates that he had a MVA in 1977 with C4-5 injury that resulted in him been a Quadriplegic. Due to his bedbound and immobility status he has had multiple pressure ulcers over the years that have resulted in hospital admission and rehab stays. Other medical history include, HTN, hyperlipidemia, Sacral pressure ulcer, Right hip pressure ulcer, Constipation, depression. Bilateral arm contractures, bladder cancer, prostate cancer, urostomy and colostomy, aspiration pneumonia, neuropathy and MRSA.

On 9/23/16 I met with Mr. Russell at the Covenant Occupational Medicine. Mr. Russell said his pain level is at a 1 to 2 now. He is able to tolerate sitting, standing and walking more since starting physical therapy. He reports he is doing a home exercise program also. Dr. Eckstein said he would increase his work restrictions. He would like him to have 2 more weeks of physical therapy. He hopes at the next appointment to be released.

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.

01/14/16 Progress Report noted that the patient has severe and constant pain. It is associated with numbness, tenderness, and restricted motion. Current pain level is 8/10. The patient is here for injection to the left subtalar joint. The exam of the left ankle revealed intact skin. There was no erythema or abrasion. No signs of infection. NVI distally. Distal sensation intact and brisk capillary refill. Clinical Assessment: The patient would like to go ahead with the

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

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

As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his

I spoke with Mr. Naranjo many times since the last reporting period regarding scheduling of occupational therapy and also the MRI. Once the MRI and x-ray were done he declined going back to Dr. Branch for a follow-up appointment on 1/31/8. He has requested to see his primary care doctor’s office.

I spoke with Mr. Sutter several times since 3/2/17. Mr. Sutter moved his medical appointment from 2/23/17 to 3/2/17. I was not unable to attend nor was I able to find a co-worker to attend. I spoke with Dr. Olenyn’s office staff many times for updated scripts and next appointment time. Mr. Sutter has lymph edema to the right and left legs. He was supposed to elevated and also wears compression stocking. His legs are so big the stockings cut in. Dr. Olenyn told Mr. Sutter he must get the swelling down because that will affect the healing of the fractures. He is at high risk for infections from open skin. Some of the bones are healing but not all. Mr. Sutter continues to use a bone stimulator daily. I have spoken with Mr. Sutter and

Mr. Reid said he needs help changing positions, moving his legs, stand by assistance to supportive assistance when walking due to legs giving out. He uses a cane and a borrowed scooter. He needs help with dressing, bathing, cleaning, home maintenance, and yard work. He

Based on the medical report dated 04/14/16, the patient presents for medication maintenance. He reports ongoing pain, withdrawal symptoms such as increased pain,

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

At today's visit he is accompanied by his son in law and daughter. He reports pain in his hands and fingers that is a result of his RA. The pain starts in his fingers and radiates up his arms. He also complain of pain in his back that he contributes to his history of herniated discs. The severity of his pain is a 2/10. He decribe the pain as a shooting pain that is worst at night and when he relaxes. He states that since starting oxycodone IR 5 mg every 8 hours as needed, his pain is much better. He takes an average 1-2 prn dose daily. He feel that this regimen is effective in palliating his pain. He complain of neuropathic pain in legs, he have numbness and tingling in both lower legs. He uses Voltarin Cream BID and take Gabapentin 400mg