DOI: 5/18/2009. Patient is a 60-year old male positive developer who sustained a right shoulder injury while he was reaching for emergency shut off switch which suddenly malfunctioned. Per OMNI, he underwent 2 shoulder surgeries on 01/01/10 and 08/11/10. The only accepted body part is for the right shoulder.
Per QME report by Dr. Ram dated 07/12/12, the patient needs a lot of treatment for medical problems affecting multiple body parts of the neck, back and shoulders.
Per pain medicine re-evaluation report dated 11/23/15, the IW’s medications include gabapentin, hydrocodone-acetaminophen, pantoprazole, tizanidine, Vitamin D and Zolpidem.
Based on the pain medicine re-evaluation report dated 02/01/16, the IW complains of unchanged neck pain, low back pain which radiates down the left lower extremity and upper extremity pain, bilaterally in the arms, fingers and hands. The pain is aggravated …show more content…
The IW reports chronic, gastroesophageal reflux disease (GERD) related to medication.
The IW reports activity of daily living limitations in the following areas due to pain: activity, ambulation, sleep, sex and per report, interference with activities of daily living due to pain over the past month is rated as 8/10.
The IW reports that the use of opioid pain medication is helpful. Areas of functional improvement include: combing/washing hair, driving, mood, shopping, sitting, sleeping and standing. IW wishes to continue this therapy based on his decreased pain and his increased level of function.
IW indicates his medication helps and is well tolerated.
On examination of the lumbar spine, there is spasm noted in the bilateral paraspinous musculature. Tenderness was noted upon palpation in the spinal vertebral area L4-S1 levels. Range of motion was moderately limited secondary to pain. Pain was significantly increased with bending to the left, bending to the right, extension and
Per QME report by Dr. Ram dated 07/12/12, the patient needs a lot of treatment for medical problems affecting multiple body parts of the neck, back and shoulders.
Per pain medicine re-evaluation report dated 11/23/15, the IW’s medications include gabapentin, hydrocodone-acetaminophen, pantoprazole, tizanidine, Vitamin D and Zolpidem.
Based on the pain medicine re-evaluation report dated 02/01/16, the IW complains of unchanged neck pain, low back pain which radiates down the left lower extremity and upper extremity pain, bilaterally in the arms, fingers and hands. The pain is aggravated …show more content…
The IW reports chronic, gastroesophageal reflux disease (GERD) related to medication.
The IW reports activity of daily living limitations in the following areas due to pain: activity, ambulation, sleep, sex and per report, interference with activities of daily living due to pain over the past month is rated as 8/10.
The IW reports that the use of opioid pain medication is helpful. Areas of functional improvement include: combing/washing hair, driving, mood, shopping, sitting, sleeping and standing. IW wishes to continue this therapy based on his decreased pain and his increased level of function.
IW indicates his medication helps and is well tolerated.
On examination of the lumbar spine, there is spasm noted in the bilateral paraspinous musculature. Tenderness was noted upon palpation in the spinal vertebral area L4-S1 levels. Range of motion was moderately limited secondary to pain. Pain was significantly increased with bending to the left, bending to the right, extension and