Case Report Nursing Care
DOI: 4/18/2003. The patient is a 71-year old male groundskeeper who sustained a work-related injury to his low back as a result of lifting heavy batteries approximately 75 pounds. As per OMNI entry, the patient is status post two lumbar surgeries and spinal cord stimulator implant. He was deemed to have reached Maximum Medical Improvement on 09/15/2009. Future medical care includes office visits, medications, physical therapy, testing, and possible removal of L3-4 pedicle screw.
Per medical report dated 10/04/16, the patient’s mediations are helpful without adverse effects. He reported 50% relief with the use of spinal cord stimulator. He continues to use fentanyl and Lidoderm patches and Norco combined, providing 50% of pain relief.
Based on the medical report dated 12/27/16, the patient reports that his pain is slightly better as he has been buying his own medications to reduce the withdrawal effects from the abrupt discontinuation imposed by the insurance company. …show more content…
It is described as aching, burning, numb, sharp, and shooting. He reports of unchanged 4/10 pain in the left leg. It is described as aching, burning, numb, sharp, shooting, and throbbing. He is not currently working. He reports difficulty with sleep. Patient was last seen on 11/29/2016. Patient reports no new medical changes.
Patient states that his Norco and Fentanyl has not gotten approved.
Patient states that with Norco and Fentanyl he was getting 70-80% relief of pain allowing him to do his Activities of Daily Living, do light meal preparation, walk and drive for short periods of time and sit for short periods of time.
On examination of the lumbar spine, there is tenderness to palpation over the bilateral lumbar facets, bilateral paravertebral thoracic spasm, bilateral paravertebral lumbar spasm, bilateral left thoracolumbar spasm, left sacroiliac joint, and bilateral left lumbosacral
Per medical report dated 10/04/16, the patient’s mediations are helpful without adverse effects. He reported 50% relief with the use of spinal cord stimulator. He continues to use fentanyl and Lidoderm patches and Norco combined, providing 50% of pain relief.
Based on the medical report dated 12/27/16, the patient reports that his pain is slightly better as he has been buying his own medications to reduce the withdrawal effects from the abrupt discontinuation imposed by the insurance company. …show more content…
It is described as aching, burning, numb, sharp, and shooting. He reports of unchanged 4/10 pain in the left leg. It is described as aching, burning, numb, sharp, shooting, and throbbing. He is not currently working. He reports difficulty with sleep. Patient was last seen on 11/29/2016. Patient reports no new medical changes.
Patient states that his Norco and Fentanyl has not gotten approved.
Patient states that with Norco and Fentanyl he was getting 70-80% relief of pain allowing him to do his Activities of Daily Living, do light meal preparation, walk and drive for short periods of time and sit for short periods of time.
On examination of the lumbar spine, there is tenderness to palpation over the bilateral lumbar facets, bilateral paravertebral thoracic spasm, bilateral paravertebral lumbar spasm, bilateral left thoracolumbar spasm, left sacroiliac joint, and bilateral left lumbosacral