Mule Care Reports
DOI: 7/13/2002. The patient is a 57-year-old male customer service representative who strained his back while moving trailers with a yard mule. Per OMNI, the patient was diagnosed with a lumbar degenerative disc disease. Per the medical report dated 08/25/15, the patient was advised to try Baclofen 10 mg #90 to make up for Ultram.
Per the medical report dated 12/16/15, the patient complains of bilateral lower back pain, which radiates down to the left lower extremity. Pain is at 8/10 with medication and 10/10 without medication. The patient has tried acupuncture, chiropractic, PT and steroid joint injections for the last 2 years with no relief. The patient also reports disturbed sleep. The patient reports constipation and dry mouth with medication. Pain is described as spasm, aching, pressure, sharp and tenderness. Pain is aggravated by bending, lifting, position change and improved by nothing. Current medications include Norco 10-325 mg 1 tablet as needed every 6 hours; Pamelor 75 mg 1 to 2 tablets nightly; gabapentin 400 mg 1 capsule 3 times daily and Baclofen 10 mg 1 tablet 3 times a day. On examination of the lumbar spine, range of motion is abnormal with pain on range of motion testing. Sitting straight leg …show more content…
Patient was diagnosed with lumbar spondylosis. Plan of care includes refill Norco tablet 10-325 mg, 1 tablet as needed, orally every 6 hours for 30 days #120; refill Pamelor tablet 75 mg, 1 to 2 tablets, orally nightly for 30 days #60; start Gabapentin capsule 400 mg, 1 capsule, orally 3 times a day for 30 days #90; and start Baclofen tablet 10 mg, 1 tablet with food or milk orally 3 times a day for 30 days #90. The patient has medication contract on file and has random urine sample screening quarterly.
Patient has been previously certified with 45 Capsules of Gabapentin 400 mg, 60 Tablets of Norco 10/325 mg and 30 Capsules of Pamelor 75 mg between 11/23/2015 and 1/7/2016 (Review
Per the medical report dated 12/16/15, the patient complains of bilateral lower back pain, which radiates down to the left lower extremity. Pain is at 8/10 with medication and 10/10 without medication. The patient has tried acupuncture, chiropractic, PT and steroid joint injections for the last 2 years with no relief. The patient also reports disturbed sleep. The patient reports constipation and dry mouth with medication. Pain is described as spasm, aching, pressure, sharp and tenderness. Pain is aggravated by bending, lifting, position change and improved by nothing. Current medications include Norco 10-325 mg 1 tablet as needed every 6 hours; Pamelor 75 mg 1 to 2 tablets nightly; gabapentin 400 mg 1 capsule 3 times daily and Baclofen 10 mg 1 tablet 3 times a day. On examination of the lumbar spine, range of motion is abnormal with pain on range of motion testing. Sitting straight leg …show more content…
Patient was diagnosed with lumbar spondylosis. Plan of care includes refill Norco tablet 10-325 mg, 1 tablet as needed, orally every 6 hours for 30 days #120; refill Pamelor tablet 75 mg, 1 to 2 tablets, orally nightly for 30 days #60; start Gabapentin capsule 400 mg, 1 capsule, orally 3 times a day for 30 days #90; and start Baclofen tablet 10 mg, 1 tablet with food or milk orally 3 times a day for 30 days #90. The patient has medication contract on file and has random urine sample screening quarterly.
Patient has been previously certified with 45 Capsules of Gabapentin 400 mg, 60 Tablets of Norco 10/325 mg and 30 Capsules of Pamelor 75 mg between 11/23/2015 and 1/7/2016 (Review