Pain Counseling Disorders: A Case Study

At today’s visit she is found sitting in the chair, she is awake, alert, and confused. I am asked to seek this pain for new onset pain. The patient complains of acute pain in pubic area and right hip area, pain is dull, achy, severity 4/10, pain is worse with walking. At this time the patient is not taking anything for pain. The ALF staff reports that the patient has daily anxiety and has to be given Ativan three times daily. The patient ambulates with a walker. Gait is

On Exam:  BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the

Patient has a history of a myocardial infarction (MI, or also known as a heart attack) in 2004, she had a hip pinning in 2005, and a traumatic amputation of fingers on her left hand in 1974 from a lawnmower accident.

Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last

DOI: 06/04/2008. The patient is a 61-year-old female dispatcher who sustained a work-related injury to her right hand and arm due to repetitive duties. As per OMNI entry, she is status post right proximal median nerve decompression on 05/12/11 and right carpal tunnel release on 09/26/11.

Based on the latest follow-up evaluation progress report dated 03/02/16, the patient complains of right shoulder pain and stiffness. He states that his shoulder feels sore. He states that his pain is aggravated by the cold weather and over activity. The patient has not attended physical therapy for some time due to travel outside of the country. He is using an analgesic cream.

Per the panel QME on 12/29/15 by Dr. Matan, it was noted that the IW will need continuing medical care for the remainder of his life. Recommendation was made to see Dr. Lee for discussion of additional surgery. It was noted that the IW continues to take Dilaudid 16 mg per day which is a heavy dose. He opined that by this time, the IW is addicted to this medication. In

Per the IME report on 4/28/16 by Dr. Pierce Ferriter, the patient reports that he is actively treating with physical therapy and chiropractic treatment at a frequency of 3 to 4 times per week. The patient’s diagnoses include resolved lumbar strain, resolved cervical strain, resolved left shoulder strain and resolved right knee strain. There is no medical necessity for further physical therapy, orthopedic treatment of diagnostic testing based on examination.

Per the AME report dated 07/08/15, the patient was deemed P & S with regard to her right knee and lumbar spine as of this date. Future medical care includes ongoing exercise program, occasional orthopedic visits, brief periods of PT, anti-inflammatory medications for flares, prescription medications and periodic injections.

At today's visit, she is awake, alert and oriented times 3. . She complains of back pain that radiates to her abdomen and down her legs. She describes the pain as deep ache that is aggravated with movements with a severity of 8/10. She states that her pain has worsened and that her current pain regimen is not effective. She states she has been taking her Dilaudid every 4 hours. She stated that she had fentanyl 50 mcg patches from what she uses to take previously. She states that she used her 50mcg patch and her pain had

Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.

Patient was diagnosed with left shoulder pain, status post rotator cuff repair on 07/12/2013, right thigh pain and chronic low back and right lower extremity pain.

prescribed methylpredisone 4mg for 6 days and ibuprofen 600 mg PRN for pain. Her last

Based on the medical report dated 05/ 2616, the patient complains of headaches and stabbing upper back and shoulder blade pain radiating to her lower back. She also has neck pain, described as burning. Pain is rated as 8/10 to the neck, lower and middle back and head. When she is on medications, her neck and mid/low back pain and her headaches reduced to a 4/10. She gets anxiety and it is related to her rapid heart rate, s which makes it feel she is in pain and this

A review of her medical records indicated that she suffers from uncontrolled hypertension with blood pressure that is elevated in mostly in the morning. She suffers from chronic anxiety which is problem related to her unrelieved pain. She also suffers from chronic anemia which is managed with iron.