Voluntary Observation Report

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current subjective complaints (from claimant) and objective observations: Mr. Anderson continues to walk using 2 canes. He reports that since having the implanted spinal cord device the rib pain is better. There is still swelling in the battery pack implantation site. He continues to report thoracic and lumbar spine pain. He is able to sit without moving or changing position. He reports not sleeping well due to pain. He said the spinal cord stimulator causes vibrations in his stomach. He is not able to tolerate that for a length of time. Boston Scientific has been contacted several times and they have made adjustments. They continue to make changes.

Review of claimant’s stated pain/limitations: He continues to rate his pain at 8. Mr.
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Anderson at the office of Dr. Shah. We had a long wait. This appointment was originally canceled and moved to today's date. Dr. Shah took a lot of time to review what has been done to treat his back pain. The spinal cord stimulator is being used about 8 to 9 hours per day. He has a lot of vibrations in his abdomen and he will use the device until he cannot tolerate it further. Dr. Shah will have Boston Scientific contact him and make more adjustments. Dr. Shah said this is not uncommon. At this point, Dr. Shah said there is nothing he can offer surgically. He wants Mr. Anderson to continue now with the pain management side to control his pain with medications. At this point, he is at MMI from a surgical standpoint. He has no further appointments. The appointment with Dr. Rampersaud was moved from 8:45 am to 3:45 pm the same day. Due to the move of the appointment, I was unable to attend. Mr. Anderson called me with an update. He said that his medications stayed the same this time. Dr. Rampersaud spoke with him and gave him a prescription to a new medication called Nucynta. He is planning on changing his pain medication to this. I have some concerns about this medication that I wanted to address with Dr. Rampersaud. Mr. Anderson has Barrets disease, also I would like to know if the monitoring of this medication is done through urine or blood and if it is accurate. Mr. Anderson consistantlyhas negative drug screens even while…show more content…
Anderson will continue to meet with Boston Scientific to try and correct the vibrations he feels in his stomach. This will allow him to use the device fully and for more hours of the day. Change Mr. Anderson’s narcotic medications to Nucynta. Continue to decrease the pain medications.

Diagnosis: Other spondylosis with radiculopathy lumbar region, other spondylosis with radiculopathy lumbosacral region, Sacroiliitis, Sacrococcygeal disorders, low back pain, other intervertebral disc displacement, lumbar region, and Thoracic Neuritis.

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