DOI: 10/10/2003. The patient is a 64-year-old male truck driver who sustained injury when he slipped and fell on the wet concrete near the truck wash pump. Per OMNI, the patient had a back and right knee contusion. He had a right L3-L4 laminectomy on 03/11/04.
Per medical report dated 1/7/16 by Dr. Carl Shin, the patient was seen for periodic evaluation of lower back pain. He had a lumbar epidural injection back on 9/4/15. He says he is still having benefit with the injection. He says he will occasionally have numbness down the left leg, but he is not hunched over as he was before the procedure. He is having benefits for at least 4 months now. He says he has 1 episode where he fell about a week ago. He says he thinks that he might be dragging …show more content…
With the tramadol, it drops to 3/10. Patient states with the medication, he is able to stand and weight-bear for longer periods of time. He is able to walk for about 30 minutes longer with the medications than without the medications. He is able to complete his grocery shopping and do activities around his home with the medications, that he is not able to do without the medications. He says when the pain is 9/10, he is fairly sedentary; but when the pain is 3/10, after the medication, he is able to stay active. Patient denies any side effects. Patient has not had aberrant behavior. He does have a signed opiate agreement on file. Random urine drug screens and occasional CURES reports were …show more content…
Current medications include tramadol 50 mg 1 tablet 4 times daily, Naprosyn 550 mg 1 tablet twice daily and beta blocker/diuretic.
Of note, the last urine drug screen is not available. Patient has allergies with codeine and other opiates.
IW was diagnosed with chronic low back and bilateral lower extremity pains, successful bilateral L5-S1 transforaminal epidural steroid injection on 09/04/2015 and lateral bilateral obliques and coned lateral L5-S1 views has the impression of age-related multilevel degenerative disk disease.
He was given a prescription for tramadol 50 mg # 120 with 3 refills, Naprosyn 500 mg #60 with 3 refills
Treatment plan includes continuation with the tramadol as it has been providing satisfactory response, flexion/extension studies of the lumbar spine to evaluate the stability of the 7-mm retrolisthesis at L1-L2, the 5-mm retrolisthesis at L2 on L3 and the anterolisthesis measuring 5 .3 mm at L4 on L5.
Next follow-up is in 2
Per medical report dated 1/7/16 by Dr. Carl Shin, the patient was seen for periodic evaluation of lower back pain. He had a lumbar epidural injection back on 9/4/15. He says he is still having benefit with the injection. He says he will occasionally have numbness down the left leg, but he is not hunched over as he was before the procedure. He is having benefits for at least 4 months now. He says he has 1 episode where he fell about a week ago. He says he thinks that he might be dragging …show more content…
With the tramadol, it drops to 3/10. Patient states with the medication, he is able to stand and weight-bear for longer periods of time. He is able to walk for about 30 minutes longer with the medications than without the medications. He is able to complete his grocery shopping and do activities around his home with the medications, that he is not able to do without the medications. He says when the pain is 9/10, he is fairly sedentary; but when the pain is 3/10, after the medication, he is able to stay active. Patient denies any side effects. Patient has not had aberrant behavior. He does have a signed opiate agreement on file. Random urine drug screens and occasional CURES reports were …show more content…
Current medications include tramadol 50 mg 1 tablet 4 times daily, Naprosyn 550 mg 1 tablet twice daily and beta blocker/diuretic.
Of note, the last urine drug screen is not available. Patient has allergies with codeine and other opiates.
IW was diagnosed with chronic low back and bilateral lower extremity pains, successful bilateral L5-S1 transforaminal epidural steroid injection on 09/04/2015 and lateral bilateral obliques and coned lateral L5-S1 views has the impression of age-related multilevel degenerative disk disease.
He was given a prescription for tramadol 50 mg # 120 with 3 refills, Naprosyn 500 mg #60 with 3 refills
Treatment plan includes continuation with the tramadol as it has been providing satisfactory response, flexion/extension studies of the lumbar spine to evaluate the stability of the 7-mm retrolisthesis at L1-L2, the 5-mm retrolisthesis at L2 on L3 and the anterolisthesis measuring 5 .3 mm at L4 on L5.
Next follow-up is in 2