DOI: 03/13/2012. Patient is a 40-year old female housekeeper who sustained injuries to her back, left knee, and right shoulder when she slipped on water and fell in the bathroom. Per OMNI, patient is status post left knee arthroscopy with chondroplasty and meniscectomy on 08/09/2012.
In an office visit dated 11/20/15, patient presents with chronic left knee, right shoulder and low back pain. Current medications include Pantoprazole-protonix 20 mg, diclofenac sodium 1.5 %, and Norco 7.5-325 mg.
Based on the office visit note dated 01/08/16, the patient presents with chronic back, left knee and right shoulder pain.
Patient reports that she continues to have persistent pain that is worse with increased activity. She did see Dr. Krinsky and left knee surgery was recommended.
She …show more content…
Patient’s gait was antalgic.
Current medications include Pantoprazole-protonix 20 mg 1-2 capsule s daily, diclofenac sodium 1.5% to be applied to affected areas 3 times a day, Norco 7.5-352 mg 1 tablet daily as needed and Capsaicin 0.075% cream to be applied to affected area 3 times a day.
Diagnoses include left knee pain, lumbar intervertebral disc displacement, lumbar spine sprain and pain disorder with related psychological factors.
He was given a prescription for gabapentin and Capsaicin cream. Diclofenac sodium, Norco and pantoprazole were discontinued.
Patient will start on gabapentin to see if this will help with neuropathic pain. She has trialed tramadol in the past without benefit. If she fails on gabapentin, she may require a long-acting opioid medication. The 9/30/15 confirmatory urine screen report was reviewed which is negative for all entities.
Patient has been previously denied with 1 Container of Capsaicin 0.075% Cream on 12/08/15 (Review 241441).
Current request is for 1 Container of Capsaicin Cream 0.075% Cream; and 60 Tablets of Gabapentin 600 mg between 1/18/2016 and
In an office visit dated 11/20/15, patient presents with chronic left knee, right shoulder and low back pain. Current medications include Pantoprazole-protonix 20 mg, diclofenac sodium 1.5 %, and Norco 7.5-325 mg.
Based on the office visit note dated 01/08/16, the patient presents with chronic back, left knee and right shoulder pain.
Patient reports that she continues to have persistent pain that is worse with increased activity. She did see Dr. Krinsky and left knee surgery was recommended.
She …show more content…
Patient’s gait was antalgic.
Current medications include Pantoprazole-protonix 20 mg 1-2 capsule s daily, diclofenac sodium 1.5% to be applied to affected areas 3 times a day, Norco 7.5-352 mg 1 tablet daily as needed and Capsaicin 0.075% cream to be applied to affected area 3 times a day.
Diagnoses include left knee pain, lumbar intervertebral disc displacement, lumbar spine sprain and pain disorder with related psychological factors.
He was given a prescription for gabapentin and Capsaicin cream. Diclofenac sodium, Norco and pantoprazole were discontinued.
Patient will start on gabapentin to see if this will help with neuropathic pain. She has trialed tramadol in the past without benefit. If she fails on gabapentin, she may require a long-acting opioid medication. The 9/30/15 confirmatory urine screen report was reviewed which is negative for all entities.
Patient has been previously denied with 1 Container of Capsaicin 0.075% Cream on 12/08/15 (Review 241441).
Current request is for 1 Container of Capsaicin Cream 0.075% Cream; and 60 Tablets of Gabapentin 600 mg between 1/18/2016 and