Skin Injury: A Case Study

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

D-This writer agreed to meet with the patient as he was placed hold to attend group. Reported stability on his current dose and denies the need for a dose increase when offered by this writer. This writer reviewed the patient's record and learned that he obtained his 3rd take home bottle on 01/04/2017. The patient is aware that he in order for him to obtained the 4th take home bottle, he must attend the take home bottle group. Addressing his medication, this writer noticed that the patient has not refilled the following medications:

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

DOI: 12/5/2013. The patient is a 57-year-old female precertification technician who sustained a work-related injury to her head, neck, lumbar spine, and right knee after slipping and falling on icy sidewalk. As per OMNI entry, she was diagnosed with head/scalp injury, status post concussion, cervical strain, headaches, and right knee medial meniscal tear status post surgery on 06/04/2014.

Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is

Patient has been previously certified with 4 Butrans Patches 10 mcg/hr on 04/12/16 ( Review 256727).

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.

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

Regardless of what type of medication the patient is asking for, Jerry is still limited by his LPN and medical assistant scope of practice. If Dr. Williams does not prescribe the medication, Jerry can't call in a refill for the medication. Factors that may influence Jerry's decision to refill this medication include that the patient states he is a

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.

The pharmacist must offer to discuss the unique drug therapy regimen of each Medicaid recipient when filling prescriptions for them. Each patient must be made an offer to be counseled by the pharmacist. The items to be addressed include, the name of the drug, intended use of expected action, common side effects and their avoidance, techniques for self-monitoring, proper storage, potential drug-drug or drug-food contraindications, refill

D-The patient requested an increase on her dose as she reports that she is experiencing chills. When asked as to what alternatives has done to address the chills rather than using illicit drugs. The patient reports she's been taking each day at time and used relaxation techniques; however, at times the "chills" can be unbearable to the point the patient does not want to relapse because she's been drug free for over a year, at which this writer provided positive feedback for the patient recovery process. Furthermore, this writer and the patient discussed the suspension of the patient take home bottles as the patient reports that the reason why the bottles were suspended was due to her medication; however, the patient reports she provided the clinic with an updated letter from her psychiatrist and notification that she is no longer prescribed with Hydroxyzone and wants to apply for all of her take homes. This writer addressed with the patient about program policy about medication/take home bottles. Furthermore, two of the patient's medication needs an updated RX script before the patient request can be reviewed. Also, a letter from her psychiatrist once again about the patient compliance with treatment and medication management. The patient reports she can get the updated script by next as this writer will assist obtaining an updated letter from her psychiatrist about the patient's overall treatment. This writer completed the dose change request form to increase the patient's dose by 5mgs.

DOI: 8/6/2014. Patient is a 58-year-old male building service worker who sustained injury to his head while he was working below, a co-worker installing a riser lost his balance and the riser weighing 150-200 pounds fell on his head. Per OMNI entry, he was initially diagnosed with closed head injury and possible concussion.

Current request is for 60 Tablets of Vicodin 5/300 mg; 1 Miralax 527 grams with 4 Refills; and 30 Tablets of Trazodone 50 mg with 4 Refills between 9/27/2016 and