DOI: 9/22/2006. The patient is a 46-year-old female sales representative who sustained cumulative trauma to her back.
Based on the progress report dated 07/26/16, the patient complains of same aching pain of the low back, which radiates to the buttocks and posterior legs. She has numbness at the top of her right foot. She takes Norco and ibuprofen with good relief and tolerates it well. Pain levels are 8-9/10 without medication, coming down to 5-6/10 with medication. Her pain is worse with sitting, standing, walking, bending and lifting. It is decreased with injections, medication and lying down. Functional improvement allows her to take care of her home. She is able to go to the store, do household chores or walk longer and be on her feet longer and provide for self-care. She is interested in trying acupuncture to see if it can decrease her …show more content…
On examination of the lumbar spine, there is tenderness in the lower paraspinal muscles and facets L5 through S1. Range of motion is diminished in both flexion and extension. She has pain with both. Sensation is decreased in the anterior right foot. Reflexes of the patella are trace. Achilles are 1 +. Straight leg raising is positive bilaterally, worse on the left causing pain down the posterior thighs. Patrick's causes low back pain. Strength of bilateral hip flexors and bilateral knee extension/flexion is 5-/5.
Patient has bilateral varicosities on her extremities. Gait is antalgic.
Impressions include chronic low back pain, lumbar discogenic pain, lumbar degenerative disc disease, bilateral chronic L5-S1 radiculitis, lumbar myofascial pain syndrome and chronic pain syndrome.
He was given a prescription for Norco 5/325 mg twice daily as needed #60, which has been significantly helpful. She tolerates it well. There has been no aberrant drug behavior. She is active on her medication.
Last opioid/treatment agreement was signed on
Based on the progress report dated 07/26/16, the patient complains of same aching pain of the low back, which radiates to the buttocks and posterior legs. She has numbness at the top of her right foot. She takes Norco and ibuprofen with good relief and tolerates it well. Pain levels are 8-9/10 without medication, coming down to 5-6/10 with medication. Her pain is worse with sitting, standing, walking, bending and lifting. It is decreased with injections, medication and lying down. Functional improvement allows her to take care of her home. She is able to go to the store, do household chores or walk longer and be on her feet longer and provide for self-care. She is interested in trying acupuncture to see if it can decrease her …show more content…
On examination of the lumbar spine, there is tenderness in the lower paraspinal muscles and facets L5 through S1. Range of motion is diminished in both flexion and extension. She has pain with both. Sensation is decreased in the anterior right foot. Reflexes of the patella are trace. Achilles are 1 +. Straight leg raising is positive bilaterally, worse on the left causing pain down the posterior thighs. Patrick's causes low back pain. Strength of bilateral hip flexors and bilateral knee extension/flexion is 5-/5.
Patient has bilateral varicosities on her extremities. Gait is antalgic.
Impressions include chronic low back pain, lumbar discogenic pain, lumbar degenerative disc disease, bilateral chronic L5-S1 radiculitis, lumbar myofascial pain syndrome and chronic pain syndrome.
He was given a prescription for Norco 5/325 mg twice daily as needed #60, which has been significantly helpful. She tolerates it well. There has been no aberrant drug behavior. She is active on her medication.
Last opioid/treatment agreement was signed on