DOI: 03/11/2004. Patient is a 34-year-old female shift manager who sustained a work-related injury to her back and bilateral upper extremities when she slipped and fell on wet floor. Patient is diagnosed with cervical sprain, right shoulder sprain, and lumbosacral disc disease at L3 to L4, L4 to L5, and L5 to S1 levels. She is status post lumbar laminectomy and fusion.
Per medical report dated 2/24/16 by Dr. Quesada, the patient reports pain along the low back, accompanied by occasional weakness of both legs with numbness and tingling. She was provided a refill prescription for the following medications: gabapentin 250/5 cc liquid 5mL orally 2 times a day, for 30 days, #1 bottle; ranitidine 15 cc/1mL 2 teaspoons orally 2 times a day, for 30 …show more content…
She reports of pain in her neck, right shoulder, and lower back and leg, rated as 7-9/10.
On examination, there is tenderness upon palpation of the lumbosacral spine and sacroiliac joint bilaterally. Muscle spasms are noted. Range of motion (ROM) is decreased. Straight leg raise (SLR) is positive.
Patient is in mild distress. He is wearing a lumbar brace and ambulating with a walker.
Current medications include ranitidine, gabapentin, estazolam and tizanidine.
Review of systems is positive for change in appetite, chills, fatigue, sweats, weight loss, blurred or double vision, dizziness, nasal congestion, sneezing, sore throat, congestion, cough, diarrhea, nausea and vomiting, frequent urination, nighttime urination, rash and itching, redness, light headedness, weakness, anxiety and depression, and diabetes.
He was given a refill prescription for the following medications: gabapentin 250/5 cc liquid 5mL orally 2 times a day, for 30 days, #1 bottle; ranitidine 15 cc/1mL 2 teaspoons orally 2 times a day, for 30 days, #1 bottle; estazolam 2 mg tablet, 1 tablet orally once a day, #30 tablets; tizanidine 4 mg 1 tablet orally at bedtime, #30 tablets; and Norco 7.5/325 mg/ 15 cc liquid, 2 to 3 teaspoons orally 2 times a day for 30 days #1
Per medical report dated 2/24/16 by Dr. Quesada, the patient reports pain along the low back, accompanied by occasional weakness of both legs with numbness and tingling. She was provided a refill prescription for the following medications: gabapentin 250/5 cc liquid 5mL orally 2 times a day, for 30 days, #1 bottle; ranitidine 15 cc/1mL 2 teaspoons orally 2 times a day, for 30 …show more content…
She reports of pain in her neck, right shoulder, and lower back and leg, rated as 7-9/10.
On examination, there is tenderness upon palpation of the lumbosacral spine and sacroiliac joint bilaterally. Muscle spasms are noted. Range of motion (ROM) is decreased. Straight leg raise (SLR) is positive.
Patient is in mild distress. He is wearing a lumbar brace and ambulating with a walker.
Current medications include ranitidine, gabapentin, estazolam and tizanidine.
Review of systems is positive for change in appetite, chills, fatigue, sweats, weight loss, blurred or double vision, dizziness, nasal congestion, sneezing, sore throat, congestion, cough, diarrhea, nausea and vomiting, frequent urination, nighttime urination, rash and itching, redness, light headedness, weakness, anxiety and depression, and diabetes.
He was given a refill prescription for the following medications: gabapentin 250/5 cc liquid 5mL orally 2 times a day, for 30 days, #1 bottle; ranitidine 15 cc/1mL 2 teaspoons orally 2 times a day, for 30 days, #1 bottle; estazolam 2 mg tablet, 1 tablet orally once a day, #30 tablets; tizanidine 4 mg 1 tablet orally at bedtime, #30 tablets; and Norco 7.5/325 mg/ 15 cc liquid, 2 to 3 teaspoons orally 2 times a day for 30 days #1