DOI: 11/5/2011. Patient is a 65-year-old female certified nursing assistant who sustained injury when she slipped and fell while giving patient a bath, hitting her left knee and hip and injuring her low back. The patient underwent complex revision left total knee arthroplasty on 10/27/2015 and also undergone left knee arthroscopic capsular release and left knee manipulation under anesthesia on 1/22/2016.
Based on the medical report dated 11/10/16 by Dr. Fieser, the patient presents for left knee pain and right knee pain. Left knee pain is associated with numbness, tingling and weakness.
The pain is aggravated by prolonged walking/standing, lifting and carrying items. The pain is relieved with resting, lying down, taking medication, and elevating the affected area. She has been using a cane for gait assistance. Pain level has remained unchanged since last visit. Patient rates her pain with mediations as 4/10 and without medications as 5/10. Quality of sleep is good. Activity level has remained the same.
She continues to note elevated pain in her left knee.
Patient notes that all of her medication were denied this last month so she was forced to pay out of pocket to maintain the relief that she requires to remain functional on a daily basis. She denies any side effects.
Inspection of the …show more content…
Medications decrease pain and optimize function and activities of daily living. Of note, Controlled Substance Utilization Review and Evaluation System (CURES) report dated 11/10/16 is appropriate for previous prescription and
Based on the medical report dated 11/10/16 by Dr. Fieser, the patient presents for left knee pain and right knee pain. Left knee pain is associated with numbness, tingling and weakness.
The pain is aggravated by prolonged walking/standing, lifting and carrying items. The pain is relieved with resting, lying down, taking medication, and elevating the affected area. She has been using a cane for gait assistance. Pain level has remained unchanged since last visit. Patient rates her pain with mediations as 4/10 and without medications as 5/10. Quality of sleep is good. Activity level has remained the same.
She continues to note elevated pain in her left knee.
Patient notes that all of her medication were denied this last month so she was forced to pay out of pocket to maintain the relief that she requires to remain functional on a daily basis. She denies any side effects.
Inspection of the …show more content…
Medications decrease pain and optimize function and activities of daily living. Of note, Controlled Substance Utilization Review and Evaluation System (CURES) report dated 11/10/16 is appropriate for previous prescription and