Dr. Muldowny Case Summary
DOI: 2/26/2016. Patient is a 47-year-old male truck driver who sustained a work-related injury when he was driving an 18-wheeler, another person driving a pickup truck pulled out across the intersection, he attempted to swerve away from the vehicle and the other driver was killed on the scene. As per OMNI notes, he was initially diagnosed with herniated lumbar disc, post-traumatic stress disorder and post-concussion.
Based on the medical report dated 07/ 12/16 by Dr. Muldowny, the patient returns in follow-up of his neck and back. There has been no significant change in his symptoms.
Low back pain is rated as a 9/10. It is radiating into both legs and ankles (describes shocking sensation into right hip at night).
In addition, he presented
with neck pain, rated as a 9/10. It is radiating to down both arms (both shoulders). The symptom started 6 months ago. Important triggers include light.
He was scheduled for a lumbar epidural injection but decided not to proceed at the last minute. He still not sure he wants to do it. He seems to be anxious about the injection itself. He thinks he wants to continue with medication at this point and see how things go.
On examination of the spine/ribs/pelvis, motion is limited secondary to pain.
Patient was diagnosed with intervertebral disc disorders with radiculopathy of the lumbar region and sprain of the ligaments of the cervical spine.
He was given a prescription for Norco and tramadol.
Recommendation was made for referral to pain management.
Current request is for
1 Referral to a Pain Management Specialist between 7/15/2016 and 9/13/2016
Based on the medical report dated 07/ 12/16 by Dr. Muldowny, the patient returns in follow-up of his neck and back. There has been no significant change in his symptoms.
Low back pain is rated as a 9/10. It is radiating into both legs and ankles (describes shocking sensation into right hip at night).
In addition, he presented
with neck pain, rated as a 9/10. It is radiating to down both arms (both shoulders). The symptom started 6 months ago. Important triggers include light.
He was scheduled for a lumbar epidural injection but decided not to proceed at the last minute. He still not sure he wants to do it. He seems to be anxious about the injection itself. He thinks he wants to continue with medication at this point and see how things go.
On examination of the spine/ribs/pelvis, motion is limited secondary to pain.
Patient was diagnosed with intervertebral disc disorders with radiculopathy of the lumbar region and sprain of the ligaments of the cervical spine.
He was given a prescription for Norco and tramadol.
Recommendation was made for referral to pain management.
Current request is for
1 Referral to a Pain Management Specialist between 7/15/2016 and 9/13/2016