Anxiety Disorders Case Summary
DOI: 3/28/2002. Patient is a 45-year old female payroll specialist who sustained injuries to her bilateral upper extremities due to repetitive job duties. Patient is currently diagnosed with other chronic pain; complex regional pain syndrome I of right lower limb; other constipation; and myalgia.
Per medical report dated 11/20/2015, patient reports that her neck pain has become more bothersome and is having muscle spasms. She also reports severe constipation while taking Oxycontin and Nucynta. The patient is prescribed with Zanaflex at bedtime to help relieve the pain and spasms; and Amitiza to help with the constipation. She is also referred to a psychologist to help with the psychosocial aspect of her pain. As per office notes dated 6/20/16, …show more content…
Straight leg raise is positive bilaterally. Faber’s exam is positive on the bilateral low back and right hip. Strength are decreased in the cervical and lumbar region. Sensation are hypersensitive bilaterally for C5, C6, C7, and C8. L2-S1 sensory to light touch. Bilateral upper extremity and left lower extremity examination revealed abnormal during inspection, hypersensitivity, weakness, swelling, decreased range of motion, and movements limited. Activities of daily living impaired by pain ranged from 3 to 9. As per discussion, the patient states that her pain has increased over the last month as summer heat has significantly increased. She is still experiencing severe opioid induced constipation. She takes Miralax daily but states that it is not adequate. The provider will request for Movantik for the patient as the medication is specifically for opioid induced constipation. The patient reports that she wakes up with severe flexion to the right foot and must gently massage the foot and press it onto a flat surface to stop the contraction. She also has experienced increased swelling color changes to the bilateral feet. As per provider's recommendation, the patient should continue with her current medication regimen as the regimen has been effective for her and that other
Per medical report dated 11/20/2015, patient reports that her neck pain has become more bothersome and is having muscle spasms. She also reports severe constipation while taking Oxycontin and Nucynta. The patient is prescribed with Zanaflex at bedtime to help relieve the pain and spasms; and Amitiza to help with the constipation. She is also referred to a psychologist to help with the psychosocial aspect of her pain. As per office notes dated 6/20/16, …show more content…
Straight leg raise is positive bilaterally. Faber’s exam is positive on the bilateral low back and right hip. Strength are decreased in the cervical and lumbar region. Sensation are hypersensitive bilaterally for C5, C6, C7, and C8. L2-S1 sensory to light touch. Bilateral upper extremity and left lower extremity examination revealed abnormal during inspection, hypersensitivity, weakness, swelling, decreased range of motion, and movements limited. Activities of daily living impaired by pain ranged from 3 to 9. As per discussion, the patient states that her pain has increased over the last month as summer heat has significantly increased. She is still experiencing severe opioid induced constipation. She takes Miralax daily but states that it is not adequate. The provider will request for Movantik for the patient as the medication is specifically for opioid induced constipation. The patient reports that she wakes up with severe flexion to the right foot and must gently massage the foot and press it onto a flat surface to stop the contraction. She also has experienced increased swelling color changes to the bilateral feet. As per provider's recommendation, the patient should continue with her current medication regimen as the regimen has been effective for her and that other