Patient Case Study: Shifting Patients
DOI: 07/01/2005. Patient is a 68-year-old male dialysis center director who sustained injury to his back while lifting patients at work. Per OMNI entry, he was diagnosed with low back herniation. IW was deemed at maximum medical improvement (MMI) by QME Dr. Conrad on 04/10/06. Future medical care includes surgery, physician visits and medications as needed.
Per office visit note dated 11/10/2016, patient’s medications included gabapentin 600mg, Soma 350mg, Ttrazodone 50mg, and Norco 7.5/325mg.
Based on the medical report dated 01/27/17, the patient complains of pain and discomfort located over the back. Pain radiates towards the right more than the left leg, down to the foot. He describes it as shooting pain, spasm and tingling feeling. Pain is …show more content…
rated 5/10.
He does have problems with lifting that aggravates with carrying and exercise, even reaching and cold weather. The medication has been helpful and effective for him. He denies any adverse reactions and side effects of the medication. He uses trazodone for sleep, but still has problems sleeping due to back pain and spasms to his back. Some days are better than others. He is otherwise functional with activities of daily living in terms of self-care, grooming and hygiene, but needs assistance with driving and cleaning.
On examination, the sacroiliac joint compression test is positive, bilaterally. Slump test is positive on the right. Lumbar spine lordosis is decreased. Motor strength testing shows 4/5 with bilateral hip flexion, bilateral knee extension and bilateral ankle dorsiflexion.
Review of systems is positive for joint stiffness and muscle cramps/spasms.
Current medications include gabapentin 600 mg 1 tablet every 8 hours, Soma 350 mg 1 tablet every 8 hours, trazodone 50 mg 1 tablet at bedtime and Norco 7.5/325 mg 1 tablet 4 times daily.
Patient was diagnosed with chronic low back pain, right-sided sciatica, chronic pain syndrome and myalgia.
He was given a prescription for gabapentin 600 mg 1 tablet every 8 hours #90 with 2 refills, Soma 350 mg 1 tablet every 8 hours #90 with 4 refills, trazodone 50 mg 1 tablet at bedtime #30 with 1 refill and Norco 7.5/325 mg 1 tablet 4 times day #120 with 4 refills.
He has been tolerating the oral pain medication reasonably well.
It reduces his pain during unexpected flare ups of back pain and it reduces his pain levels to a more tolerable levels where he is more functionally independent with daily activities and ultimately as a result of this, he is able to function. He denies any adverse reaction and side effects of the medication. He is stable on the medication. He will follow up in 2 months or as needed for reassessment.
Requested from the provider’s office verification on the quantity and number of refills being requested, and requested for copies of urine drug screen and Controlled Substance Utilization Review and Evaluation System (CURES) reports; however, no reports were received prior to the submission of this request to PA.
Patient has been previously certified with 25 Tablets of Norco 7.5/325 mg and 19 Tablets of Soma 350 mg (Review 284191) and 90 Tablets of Gabapentin 600mg with 1 Refill and 7 Tablets of Trazodone 50mg (Review 284189) on 11/23/16.
Current requests are for 90 Tablets of Soma 350 mg; 120 Tablets of Norco 7.5/325 mg; 30 Tablets of Trazadone 50 mg with 4 Refills; and 90 Tablets of Gabapentin 600 mg with 4 Refills between 2/8/2017 and
7/9/2017.
Per office visit note dated 11/10/2016, patient’s medications included gabapentin 600mg, Soma 350mg, Ttrazodone 50mg, and Norco 7.5/325mg.
Based on the medical report dated 01/27/17, the patient complains of pain and discomfort located over the back. Pain radiates towards the right more than the left leg, down to the foot. He describes it as shooting pain, spasm and tingling feeling. Pain is …show more content…
rated 5/10.
He does have problems with lifting that aggravates with carrying and exercise, even reaching and cold weather. The medication has been helpful and effective for him. He denies any adverse reactions and side effects of the medication. He uses trazodone for sleep, but still has problems sleeping due to back pain and spasms to his back. Some days are better than others. He is otherwise functional with activities of daily living in terms of self-care, grooming and hygiene, but needs assistance with driving and cleaning.
On examination, the sacroiliac joint compression test is positive, bilaterally. Slump test is positive on the right. Lumbar spine lordosis is decreased. Motor strength testing shows 4/5 with bilateral hip flexion, bilateral knee extension and bilateral ankle dorsiflexion.
Review of systems is positive for joint stiffness and muscle cramps/spasms.
Current medications include gabapentin 600 mg 1 tablet every 8 hours, Soma 350 mg 1 tablet every 8 hours, trazodone 50 mg 1 tablet at bedtime and Norco 7.5/325 mg 1 tablet 4 times daily.
Patient was diagnosed with chronic low back pain, right-sided sciatica, chronic pain syndrome and myalgia.
He was given a prescription for gabapentin 600 mg 1 tablet every 8 hours #90 with 2 refills, Soma 350 mg 1 tablet every 8 hours #90 with 4 refills, trazodone 50 mg 1 tablet at bedtime #30 with 1 refill and Norco 7.5/325 mg 1 tablet 4 times day #120 with 4 refills.
He has been tolerating the oral pain medication reasonably well.
It reduces his pain during unexpected flare ups of back pain and it reduces his pain levels to a more tolerable levels where he is more functionally independent with daily activities and ultimately as a result of this, he is able to function. He denies any adverse reaction and side effects of the medication. He is stable on the medication. He will follow up in 2 months or as needed for reassessment.
Requested from the provider’s office verification on the quantity and number of refills being requested, and requested for copies of urine drug screen and Controlled Substance Utilization Review and Evaluation System (CURES) reports; however, no reports were received prior to the submission of this request to PA.
Patient has been previously certified with 25 Tablets of Norco 7.5/325 mg and 19 Tablets of Soma 350 mg (Review 284191) and 90 Tablets of Gabapentin 600mg with 1 Refill and 7 Tablets of Trazodone 50mg (Review 284189) on 11/23/16.
Current requests are for 90 Tablets of Soma 350 mg; 120 Tablets of Norco 7.5/325 mg; 30 Tablets of Trazadone 50 mg with 4 Refills; and 90 Tablets of Gabapentin 600 mg with 4 Refills between 2/8/2017 and
7/9/2017.