Low Back Pain Case Study
This is a 60-year-old male with a 7/4/2005 date of injury. A specific mechanism of injury has not been described.
DIAGNOSIS: Low back pain and chronic pain syndrome
12/07/15 Progress Report indicated that the patient is upset as he has not been getting his pain medications for a long time. Apparently, his insurance has not been paying for his prescriptions. The patient complains of back pain. The pain is 4/10-scale level with the medications and 7/10-scale level without medications. Without the medications his ADL and physical function has been worse. His mood is bad and he is not sleeping well due to pain. He denies any side effects to medications. The patient is aware of the implications of chronic pain medication use including the potential …show more content…
The patient is taking Nucynta, Lyrica and ibuprofen to control his pain. The pain is 2/10 on a pain scale with medications and escalates to 8/10 on a pain scale without medications. So far, he is functional physically and mentally with his current pain management and would like to continue. He reports no adverse reactions or side effects to the medication. The patient returns to the office every three months for pain medication refills on his future medical claim as agreed upon by QME evaluation. He understands the implications of chronic pain management and would like to continue with medications.
04/14/15 Progress Report described that the patient has chronic back pain. The pain is managed with chronic pain medications. The patient is stable and functional. There are no adverse side effects to the medications. There are no signs of addiction or dependency. He continues to have lower extremity numbness and tingling. Exam of the back revealed generalized pain to palpation across the lumbar spine; tender bilateral SI joints; and limited ROM. Current medications included Nucynta, Motrin and Lyrica. Treatment plan included refill for Nucynta and Lyrica.
Treatment to date includes
DIAGNOSIS: Low back pain and chronic pain syndrome
12/07/15 Progress Report indicated that the patient is upset as he has not been getting his pain medications for a long time. Apparently, his insurance has not been paying for his prescriptions. The patient complains of back pain. The pain is 4/10-scale level with the medications and 7/10-scale level without medications. Without the medications his ADL and physical function has been worse. His mood is bad and he is not sleeping well due to pain. He denies any side effects to medications. The patient is aware of the implications of chronic pain medication use including the potential …show more content…
The patient is taking Nucynta, Lyrica and ibuprofen to control his pain. The pain is 2/10 on a pain scale with medications and escalates to 8/10 on a pain scale without medications. So far, he is functional physically and mentally with his current pain management and would like to continue. He reports no adverse reactions or side effects to the medication. The patient returns to the office every three months for pain medication refills on his future medical claim as agreed upon by QME evaluation. He understands the implications of chronic pain management and would like to continue with medications.
04/14/15 Progress Report described that the patient has chronic back pain. The pain is managed with chronic pain medications. The patient is stable and functional. There are no adverse side effects to the medications. There are no signs of addiction or dependency. He continues to have lower extremity numbness and tingling. Exam of the back revealed generalized pain to palpation across the lumbar spine; tender bilateral SI joints; and limited ROM. Current medications included Nucynta, Motrin and Lyrica. Treatment plan included refill for Nucynta and Lyrica.
Treatment to date includes