DOI: 1/21/2002. Patient is a 58-year-old male customer service representative/driver who sustained injury to his low back when he felt a pop while sitting down in his truck. Per OMNI, he had multilevel lumbar disc disease, bilateral shoulder arthropathy, and right knee arthropathy.
Urine drug screen obtained on 06/10/16 showed positive for hydrocodone, norhydrocodone, hydromorphone, and gabapentin.
Based on the medical report dated 01/19/17, the patient complains of complains of middle back pain, lower back pain, left shoulder pain, right shoulder pain and neuropathic pain. His Visual Analogue Scale score is 5/10.
Patient’s functional biomarker include 4/8 vitamins deficiency, fatigue, insomnia, depression, constipation, and B6 peripheral neuropathy/B12, folic acid.
Patient’s pain levels are decreased with the use of the medication. His function and Activities of Daily Living are also improved.
Activity level has remained the same. The patient is taking his medications as prescribed. He states that medications are effective. No side effects reported. …show more content…
Patient was diagnosed with low back pain, lumbar radiculopathy and sleep disorder.
The pts current functional status has improved with the addition of the morphine sulfate ER. Function and activities of daily livings are also better.
The patient is completely disabled, rated permanent and stationary. He continues to have significant medical residuals that require continued medical care.
Patient was given prescriptions for gabapentin 800 mg 1 tablet three times daily #90 with 3 refills, Vicoprofen 7.5/200mg 1-2 tablets ever 3-4 hours maximum of 8/day #240, Dilaudid 4 mg 1 tablet every 3-4 hours #60 and morphine sulfate ER 1 tablet twice daily
Urine drug screen obtained on 06/10/16 showed positive for hydrocodone, norhydrocodone, hydromorphone, and gabapentin.
Based on the medical report dated 01/19/17, the patient complains of complains of middle back pain, lower back pain, left shoulder pain, right shoulder pain and neuropathic pain. His Visual Analogue Scale score is 5/10.
Patient’s functional biomarker include 4/8 vitamins deficiency, fatigue, insomnia, depression, constipation, and B6 peripheral neuropathy/B12, folic acid.
Patient’s pain levels are decreased with the use of the medication. His function and Activities of Daily Living are also improved.
Activity level has remained the same. The patient is taking his medications as prescribed. He states that medications are effective. No side effects reported. …show more content…
Patient was diagnosed with low back pain, lumbar radiculopathy and sleep disorder.
The pts current functional status has improved with the addition of the morphine sulfate ER. Function and activities of daily livings are also better.
The patient is completely disabled, rated permanent and stationary. He continues to have significant medical residuals that require continued medical care.
Patient was given prescriptions for gabapentin 800 mg 1 tablet three times daily #90 with 3 refills, Vicoprofen 7.5/200mg 1-2 tablets ever 3-4 hours maximum of 8/day #240, Dilaudid 4 mg 1 tablet every 3-4 hours #60 and morphine sulfate ER 1 tablet twice daily