Symptoms And Treatment Of Chronic Pain

1471 WordsJan 13, 20166 Pages
This is a 61-year-old male with a 7/20/2011 date of injury, who fell at work and sustained injury to his left shoulder, left knee, cervical spine and lumbar spine. Diagnoses include chronic intractable low back and neck pain secondary to lumbosacral degenerative disc disease. Left shoulder pain s/p arthroscopy, chronic left knee pain, chronic pain syndrome, severe neuropathic pain, depression, history of drug abuse, and chronic daily headaches. 12/14/15 Progress Report described a follow-up visit. The patient reported worsening left knee pain X 3weeks after doing housework on his knees. He heard a pop upon standing. Since then, he is having pain with weight bearing and feeling of instability/buckling. The patient has persistent back pain…show more content…
The patient denies aberrant behaviors. Objective Findings: He has difficulty getting up from seated to standing position. He has an antalgic gait and uses a cane. There was pain with palpation of medial knee and with varus stress to medial knee. Motor strength was 5/5. Cervical and lumbar ROM is limited. Sensations are intact. Treatment plan included SCS and medications. The goal is to decrease the use of narcotics and medications in general. Follow-up is in one month. UDS and CURES reports were reviewed. 09/21/15 Progress Report indicated that the patient is maintaining usual medications for chronic pain syndrome. He is awaiting evaluation with the spine surgeon for SCS placement and/or injections under fluoroscopy. He had this done a couple of years ago. Current medications: Norco, Butrans, Gabapentin, and Cymbalta. The medications help control his pain. 1. Butrans Patch 20mcg 1 patch q 5 days #5, and 2. Norco 5/325mg 1 tab 4 x daily #120, 08/27/15 UDS Report showed that the patient has been consistent with Butrans and Norco. 06/30/15 Progress Report noted that the patient stated that Butrans in only authorized for 20 days. Since, he is running out of his Butrans patch, it is affecting his ability to do his ADLs and aid in ambulation. He reported that he has been using his Butrans patch for 10 days now, instead of 5 days. This is a change of circumference. The patient is feeling miserable. The pain was 7-8/10-scale level and he has not been
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