Physician Recommended 4 Separate Treatments

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This is a 68-year-old male with a 1/5/2000 date of injury. He injured his neck and upper back as a result of pushing equipment up a ramp at work. DIAGNOSIS: Postlaminectomy synd NOS 12/08/15 UDT Report was negative for all prescribed drugs including opioids and benzodiazepines; and confirmed that the patient is inconsistent with his treatment regimen. Medications prescribed: Baclofen, Butrans, Diazepam, Hydrochlorthiazide, Hydrocodone, Lexapro, Lidoderm, Lyrica, Nxium, Tizanidine and Tramadol. 12/7/15 medical report by Dr. Li identified that utilizing the neurostimulator is medically necessary and provides the best change of effective improvement for the patient. The physician recommended 4 separate treatments over the course of 30…show more content…
There was decreased range of motion and positive Spurling’s. Trigger points were noted over the bilateral trapezius, suprascapularis, and dullness to pinprick to both hands. There was weakness to grip 1st and 2nd digit opposition, and 1st and 5th digit opposition bilaterally. Deep tendon decreased 1/4 bilateral triceps/biceps. 12/2/15 orthopedic report identified neck and upper back pain that radiates to the arms, worse on the right. There is loss of grip strength and weakness in both hands and arms, primarily the right. There is a burning sensation in the arms. Exam revealed atrophy in the intrinsic muscles of both hands. There is no hyperreflexia. The patient has poor gait and wears a neck brace. He has difficulty toe walking and heel walking. The physician recommended pain management at this time. The physical exam revealed limited ROM at the cervicothoracic junction. Current medications were not documented. Treatment plan included Vista collar, medications, and revision surgery: cervical osteotomy in order to realign his spine with augmented fusion more likely to the base of the skull. 10/07/15 IMR Letter showed denial of Fobic and Tizanidine. Tizanidine was denied due lack od documentation of pain relief and functional improvement with the medication. There was no documentation of failure of first-line medications and prolonged use is not recommended by guidelines. 9/30/15 Progress report
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