Pain Case Summary
DOI: 2/10/1987. The patient is a 69-year-old male truck driver who sustained a work-related injury when he lost footing and twisted his back. As per OMNI entry, he is status post fusion at L4-S1 in 1989, with hardware removal in 1996.
Based on the progress report dated 11/20/15, the patient presents for follow up regarding his low back pain. He reports a 70% increase in pain over the past month. He attributes the increased pain to cold weather and lack of sleep.
In regards to his low back, he describes an aching pain which he rates at a 9/10. He states standing on concrete causes pain into his legs which is alleviated with sitting down.
He states the pain causes difficulty sleeping with the pain more severe and with stiffness when he wakes …show more content…
Diagnoses are failed back surgery syndrome, lumbago and lumbar degenerative disc disease.
He was given a refill prescription for Ultracet, 2 Flexeril creams as this helps with sleep, improves function and ambulation, and decreases muscle spasms. Patient will discontinue over-the-counter (OTC) Aleve. He was given prescription for a trial of Relafen 750mg 1 tablet twice daily as needed. If IW has no better improvement than OTC Aleve, will return to OTC Aleve. Medication panel was obtained on this visit.
Treatment plan includes a trial of acupuncture 2 x 4 weeks, for the lumbar spine to decrease pain and increase range of motion and functional capacity and follow up in 8 weeks.
Current request is for 2 Containers of CM4-Capsaicin 0.05% and Cyclobenzaprine 4%; and 120 Tablets of Nabumetone 750 mg between 12/30/2015 and
Based on the progress report dated 11/20/15, the patient presents for follow up regarding his low back pain. He reports a 70% increase in pain over the past month. He attributes the increased pain to cold weather and lack of sleep.
In regards to his low back, he describes an aching pain which he rates at a 9/10. He states standing on concrete causes pain into his legs which is alleviated with sitting down.
He states the pain causes difficulty sleeping with the pain more severe and with stiffness when he wakes …show more content…
Diagnoses are failed back surgery syndrome, lumbago and lumbar degenerative disc disease.
He was given a refill prescription for Ultracet, 2 Flexeril creams as this helps with sleep, improves function and ambulation, and decreases muscle spasms. Patient will discontinue over-the-counter (OTC) Aleve. He was given prescription for a trial of Relafen 750mg 1 tablet twice daily as needed. If IW has no better improvement than OTC Aleve, will return to OTC Aleve. Medication panel was obtained on this visit.
Treatment plan includes a trial of acupuncture 2 x 4 weeks, for the lumbar spine to decrease pain and increase range of motion and functional capacity and follow up in 8 weeks.
Current request is for 2 Containers of CM4-Capsaicin 0.05% and Cyclobenzaprine 4%; and 120 Tablets of Nabumetone 750 mg between 12/30/2015 and