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Iw Treatment Plan

Satisfactory Essays
DOI: 4/01/2015. The patient is a 53-year-old-male old carpenter /foreman who sustained a work- related injury while lifting a high beam when the beam slipped before being placed into the ground pushing him between the beam and leads, crushing his right ankle and foot.
Per the medical report dated 06/27/2016, the patient complaints of right ankle pain. It was noted that Elavil and Naprosyn provide relief about 20-40% each. Patient’s current medications are Ambien, Naproxen, and Gabapentin. Patient has tried Gabapentin and Tramadol which did not help. Treatment plan includes application of Voltaren gel 1% to affected area four times a day and as needed, increasing Naproxen to 500 mg, addition of omeprazole 20mg once a day, Elavil 25mg at night, and Lidoderm patches 5% for pain.

Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last
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IW is currently taking Naproxen. IW is taking gabapentin but states that it has not helped as he has some grogginess. Patient has 50% relief with current medications.

On examination of the right ankle, there is edema. Range of motion is limited in all planes. Dorsiflexion shows 15 degrees, flexion to 20 degrees and inversion/eversion of 10 degrees. There is tenderness upon palpation of the lateral and medial malleolus. Sensation is decreased. Atrophy/wasting is noted.
Assessments include ankle pain, talar fracture, impaired range of motion and persistent swelling.
Per the Request for Authorization form dated 09/19/16, IW was prescribed with Naprosyn 500 mg 1 tablet three times daily #90, omeprazole 20 mg 1 capsule daily #30 and Elavil 25 mg a t bedtime #30.
IW was advised to return to clinic as needed.
Current request is for 30 Capsules of Omeprazole 20mg; 30 Tablets of Elavil 25mg with 1 Refill; and 90 Tablets of Naprosyn 500mg with 1 Refill between 9/20/2016 and
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