This is a 46-year-old male with 04/19/05 date of crush injury to his left foot.
Diagnosis:
Left foot pain
11/16/15 Progress Report by Dr. Pang described that the patient still has a lot of pain in the left foot. The examination was WNL. Zohydro did help but still suboptimal. The SCS has not been working. The report indicated that the regimen and the side effects of the medications have been addressed and are well tolerated. There is no evidence of aberrant behaviors and the monitoring continues. The provider indicated that the patient is benefiting from the medications. Treatment plan included medications, forensic dental evaluation and follow-up with Lisa Medtronic. The provider mentioned that if the SCS starts working again, he could get …show more content…
Per ODG Guidelines, when considering on-going opioid management, several factors should be considered, including prescription from a single practitioner; lowest possible dose to improve pain; documentation of pain relief; functional status; appropriate medication use and side effects; documentation of misuse and continuing review of overall situation with regard to non-opioids means of pain control. The medication was within guidelines supported levels. The patient has been taking opioids for a long time and the requesting physician hopes to wean the patient off opiates in future. There is documentation of pain relief and improvement in functional status of the patient. Furthermore, review of the four A’s assessment has been provided and there has been discussion of risk and benefits of the opioids. There is documentation of opiate agreement, appropriate medication use and no reported misuse. Therefore, continuation of this medication is reasonable to further address her ongoing pain complaints. Recommend
Diagnosis:
Left foot pain
11/16/15 Progress Report by Dr. Pang described that the patient still has a lot of pain in the left foot. The examination was WNL. Zohydro did help but still suboptimal. The SCS has not been working. The report indicated that the regimen and the side effects of the medications have been addressed and are well tolerated. There is no evidence of aberrant behaviors and the monitoring continues. The provider indicated that the patient is benefiting from the medications. Treatment plan included medications, forensic dental evaluation and follow-up with Lisa Medtronic. The provider mentioned that if the SCS starts working again, he could get …show more content…
Per ODG Guidelines, when considering on-going opioid management, several factors should be considered, including prescription from a single practitioner; lowest possible dose to improve pain; documentation of pain relief; functional status; appropriate medication use and side effects; documentation of misuse and continuing review of overall situation with regard to non-opioids means of pain control. The medication was within guidelines supported levels. The patient has been taking opioids for a long time and the requesting physician hopes to wean the patient off opiates in future. There is documentation of pain relief and improvement in functional status of the patient. Furthermore, review of the four A’s assessment has been provided and there has been discussion of risk and benefits of the opioids. There is documentation of opiate agreement, appropriate medication use and no reported misuse. Therefore, continuation of this medication is reasonable to further address her ongoing pain complaints. Recommend