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Lumbar Discomfort Case Study

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DOI: 02/17/2006. Patient is a 41-year-old male general laborer who sustained a work-related injury to his low back as a result of lifting fire hydrants all day. Per medical report dated 8/22/2016, it was noted that per “Controlled Substance Utilization Review and Evaluation System (CURES) report,” he is taking morphine extended release (ER) 60 mg one tablet twice a day; Soma 350 mg one tablet three times a day; and Norco 10/325 mg one tablet 5 times per day. Urine drug screen obtained on 09/22/16 showed positive for hydrocodone, hydromorphone, norhydrocodone, acetaminophen, meprobamate, tramadol and desmethyltramadol. Based on the medical report dated 12/13/16, the patient presents for follow-up. Lumbar discomfort is described as sharp, aching, burning, shooting, severe and continuous, comes and goes, discomfort, pain, random, varying with activity, increasing with movement, tightness, and throbbing. It is rated as 9/10 without medications and 6/10 with medications. The symptoms are aggravated by changing positions, lifting, pulling, pushing, carrying, sitting, twisting,…show more content…
Pain/tenderness is noted at the thoraco-lumbar, lower thoracic/lumbar, upper/lower lumbar, lumbo-sacral and sacral. Moderate muscle spasms are demonstrated in the following areas: bilateral lumbar, bilateral sacroiliac, sacral, bilateral posterior pelvis/hip, and bilateral buttocks. Patient was diagnosed with lumbar pain. 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. Consult for the low back is requested. Patient has been previously certified with 45 Tablets of Soma 350 mg, 75 Tablets of Norco 10/325 mg and 30 Tablets of Morphine ER 60 mg on 09/01/16 (Review
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