Patient Case Report Sample

Satisfactory Essays
DOI: 11/14/2005. Patient is an 83 year old female demonstrator who sustained injury to her lower back while breaking down on her table.

MRI of the lumbar spine date 3/17/16 (no official report) revealed bilateral facet hypertrophy at L2-3, right disc bulge at L3-4 with bilateral facet hypertrophy, ligamentum flavum hypertrophy and canal stenosis. At L4-5 right disc bulge with facet hypertrophy,. ligamentum flavum hypertrophy and L5-S1 disc protrusion. As per medical report dated, patient complains of persistent lower back pain. She states that her pain is severe at pain scale of 8. She describes her pain as deep and aching, consistent pain radiating into the right lower extremity. She continues to have difficulty walking. She also have mentioned that she has seen an orthopedic surgeon that has a plan forher to go to physical therapy. She does continue to use the Norco which does benefit her lower back pain. She reports no side effects or sedation with medication use. She is waiting for authorization for large heating pad and they have requested random urine drug screen in her Febuary visit. Objective findings include positive heart sounds at S1 to S2 upon ausculation, positive for pain and anxiety. Tenderness and spasms are noted at the lumbar paraspinal muscles. Stiffness is also noted during motion of the lumbar spine. There is tenderness to lumbar facet joint bilaterally, sysesthesia light touch right L5 more than S1 dermatome. Strength is measure as 4/5 on right of EHL dorsiflexion
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Is the request for 120 Tablets of Norco 10/325mg medically necessary?

Please make a peer to peer with Dr. Aruna Rao at 209-576-8715.
CA MTUS Chronic pain medical treatment guidelines
ACOEM Chronic Pain; Low Back Disorders; Opioids; Stress-related Conditions
ODG Pain (Chronic); Low Back - Lumbar & Thoracic (Acute & Chronic); Mental Illness & Stress; Drug Formulary (Appendix
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