Gastritis Case Study

Decent Essays
DOI: 06/06/2007. The patient is a 51-year-old right-hand dominant female assembler who sustained injury to multiple body parts when she slipped on wet floor while moving some boxes.
As per progress report dated 4/14/16, patient is currently prescribed with Norco and Prilosec.
Based on the progress report dated 07/28/16, the patient presents for flare-up in lumbar spine symptoms. Lumbar spine pain is rated as 5-6/10 with bilateral lower extremities radicular pain, numbness and tingling. Left lower extremities symptoms are greater. Patient declines injection Norco is helpful for pain and Prilosec is helpful for gastritis. Patient is unable to take oral nonsteroidal anti-inflammatory drugs (NSAIDS) due to gastritis. Controlled Substance Utilization Review and Evaluation System (CURES) report showed sole provider of medications. It was noted that the patient has only received 2
…show more content…
Patient has no treatment since the last visit. There is increased pain and weakness. The patient presents in mild distress. The patient has difficulty rising from sitting. The patient moves with stiffness. There is mild tenderness on the lumbar, lumbar-sacral and sacral with spasms. Gait is antalgic. Bilateral straight leg raise is present. Lumbar spine range of motion shows flexion 30 degrees, flexion 10 degrees, and right and left lateral 10 degrees with pain.
Patient was diagnosed with lumbar intervertebral disc disorders with radiculopathy, lumbar region other intervertebral disc displacement, sprain of ligaments of lumbar spine, and spinal stenosis, lumbar region.
Treatment plan includes chiropractic treatment 2x a week for 3 weeks for the lumbar spine flare up post P & S and CMP to evaluate liver dysfunction due to prolonged use of narcotics.
Patient was prescribed with Norco 10/325 mg and Prilosec 20 mg.
Requested verification form the provider’s office; however, no callback/report was received prior to sending this case to
Get Access