This is a 62-year-old male with a 11/30/2015 date of injury. IW's foot caught the curb of a step, and he fell approximately 10 feet down the concrete stairs.
DIAGNOSIS: status post mechanical fall -rib fractures and knee contusion.
12/30/15 Progress Report documented that the patient reported stomach upset due to Norco. There are fractures of the right 6th, 7th and 8th ribs, where he still has pain with respiration. Since the injury, he has experienced significant pain in the left knee, headaches, dizziness, insomnia, spine pain and right shoulder pain. Back pain is mostly on the right low back radiating to the anterior thigh and knee. The pain gets better with lying on the left side with the right knee bent. Prolonged sitting and leaning …show more content…
The frequency is constant. The symptoms are exacerbated by rest and lessened by use. The patient also reported right shoulder pain. The pain is sharp, mild and constant. The patient complains of pain with motion of the shoulder. The patinet also complains of chest pain. There are no complains of dyspnea or painful respirations. Exam of the right shoulder revealed full range of motion and no tenderness on palpation. The exam of the left knee revealed tenderness on the left medial joint line and left lateral joint line. Apprehension and McMurray’s tests were negative. ROM and muscle strength were normal. Sensatiosn to light touch were intact. Current medicatiosn included Nabumetone and Orphenadrine. Traetment plan: MMi expected 01/29/16. Narcotics were not prescribed. Start Relafen for pain and Norflex for muscle. Follow-up was on 12/10/15.
11/30/15 Progress Report indicated that the patient is s/p fall. He fell approximately 10 feer and down the stairs. On arrival, he was complaining of right chest pain and right knee pain. There was right chest and left knee tenderness noted. He has CT scans and X-Rays. His work up was notable for right-sided rib fractures. The patient was counseled to stay in the hospital overnight due to multiple fractures, but he denied. He was given IV fluids. The patient was discharged with pain medication and given strict …show more content…
The patient sustained an injury due to fall on 11/30/15. There is significant pain in the left knee and right shoulder. There are also reported rib fractures, which result in painful respiration. However, there is no documentation of VAS pain levels with and without the use of medication. There is no reported functional benefit and pain relief from other opioid medications. He has tried other opioids, including Norco and Oxycontin, but had to discontinue due to side effects and intolerance. There is stomach upset noted with Norco use. Furthermore, there is no mention of the absence of aberrant behaviors and medication compliance. There were no UDS or CURES reports available for review. Currently, he is taking Naproxen for pain control. Medical necessity of Tramadol has not been substantiated. Recommend
DIAGNOSIS: status post mechanical fall -rib fractures and knee contusion.
12/30/15 Progress Report documented that the patient reported stomach upset due to Norco. There are fractures of the right 6th, 7th and 8th ribs, where he still has pain with respiration. Since the injury, he has experienced significant pain in the left knee, headaches, dizziness, insomnia, spine pain and right shoulder pain. Back pain is mostly on the right low back radiating to the anterior thigh and knee. The pain gets better with lying on the left side with the right knee bent. Prolonged sitting and leaning …show more content…
The frequency is constant. The symptoms are exacerbated by rest and lessened by use. The patient also reported right shoulder pain. The pain is sharp, mild and constant. The patient complains of pain with motion of the shoulder. The patinet also complains of chest pain. There are no complains of dyspnea or painful respirations. Exam of the right shoulder revealed full range of motion and no tenderness on palpation. The exam of the left knee revealed tenderness on the left medial joint line and left lateral joint line. Apprehension and McMurray’s tests were negative. ROM and muscle strength were normal. Sensatiosn to light touch were intact. Current medicatiosn included Nabumetone and Orphenadrine. Traetment plan: MMi expected 01/29/16. Narcotics were not prescribed. Start Relafen for pain and Norflex for muscle. Follow-up was on 12/10/15.
11/30/15 Progress Report indicated that the patient is s/p fall. He fell approximately 10 feer and down the stairs. On arrival, he was complaining of right chest pain and right knee pain. There was right chest and left knee tenderness noted. He has CT scans and X-Rays. His work up was notable for right-sided rib fractures. The patient was counseled to stay in the hospital overnight due to multiple fractures, but he denied. He was given IV fluids. The patient was discharged with pain medication and given strict …show more content…
The patient sustained an injury due to fall on 11/30/15. There is significant pain in the left knee and right shoulder. There are also reported rib fractures, which result in painful respiration. However, there is no documentation of VAS pain levels with and without the use of medication. There is no reported functional benefit and pain relief from other opioid medications. He has tried other opioids, including Norco and Oxycontin, but had to discontinue due to side effects and intolerance. There is stomach upset noted with Norco use. Furthermore, there is no mention of the absence of aberrant behaviors and medication compliance. There were no UDS or CURES reports available for review. Currently, he is taking Naproxen for pain control. Medical necessity of Tramadol has not been substantiated. Recommend