How To Write A Case Study Overdose Patient

DOI: 6/10/1988. Patient is a 72-year-old male heavy equipment operator who injured his lower back when he slipped from a scraper and fell 10 feet to the ground. He is post 4 lumbar spine surgeries.
Based on the medical report dated 12/14/15, the patient presents with severe lower back pain, which radiates to the left ankle and right calf. The patient describes the pain as an ache, deep, piercing, shooting and stabbing. The patient reports his pain without medications at 10/10 and with medications at 7/10.
Interference with their daily activities is rated as 10/10 in the last month. Symptoms are aggravated by ascending/descending stairs, bending, changing positions, daily activities, extension, flexion, jumping, lifting, pushing, rolling over in bed, running, sitting, standing, twisting and walking. Symptoms are relieved by pain medications.
The patient has not experienced any side effects to the prescribed medication and has not experienced an overdose event during the current treatment episode. The patient has not demonstrated any evidence of a current substance use disorder. On examination, the patient’s gait is antalgic. There is tenderness at the spinous, paraspinous, gluteals, piriformis, quadratus, posterior sacroiliac spine, and sciatic notch. There is pain with motion. There is pain at the buttocks area. Straight leg raise radiates pain bilaterally. There is moderate pain with range of motion. There is severe restriction on