Urine drug screen obtained on 03/16/15 showed positive for hydrocodone, hydromorphone, dihydrocodeine, norhydrocodone, carisoprodol and meprobamate.
As per progress report dated 6/8/2016, patient’s medications include Pulmicort, oxycodone, Ambien, Soma, Zantac, lisinopril, and simvastatin.
Based on the progress report dated 09/07/16 by Dr. Chow, the patient presents with left-sided lumbar back pain symptoms radiating into the left lower limb in a radiculopathic pattern. Exacerbating …show more content…
The IW’s Oswestry Disability Index score is 32 with oxycodone and 44 without oxycodone.
IW shows no signs of misuse/abuse and aberrant behavior of this medication. IW cannot tolerate nonsteroidal anti-inflammatory drugs (NSAIDS) due to gastrointestinal issues and hypertension. IW was also provided with Ambien 10 mg 1 tablet at bedtime as needed for sleep #30, as it provides 4-5 additional hours of sleep with improvement of his Activities of Daily Living. Soma 350 mg 1 tablet twice daily as needed for spasm was also prescribed #60 as it provides 30% improvement of his lumbar spasms with 30% improvement of his Activities of Daily Living. Medrol does pack #1 was also prescribed.
With current medications, patient is on up to date pain contract, consistent previous urine drug screen and no adverse effects noted.
Patient will follow-up in 3 months.
Patient has been previously certified with 60 Tablets of Oxycodone 10 mg, 15 Tablets of Ambien 10 mg and 30 Tablets of Soma 350 mg on 06/29/16 (Review 265937).
Current request is for 60 Tablets of Soma 350mg; 30 Tablets of Ambien 10mg; 120 Tablets of Oxycodone 10mg; and 1 Medrol Dose Pack between 9/13/2016 and