Sample Case Interview Report

On 2/16/17 I met Mr. Anderson and his wife at the office of Dr. Shah. This was a very lengthy appointment. Mr. Anderson reported he has pain on a 10 scale since the injection. He is very unstable while walking today. He reported that the last set of injections was very painful and he had so many spasms to the right leg that Dr. Rampersaud almost sent him over to the hospital. He has swelling to the low back "my injury site", pain to the low back with radiation to the right and left legs. He spoke for a long time about his medications being decreased and how is he going to be able to function with the decreased dose. Dr. Shah said that the swelling is soft tissue and there is no surgery to fix that. At this point he has no surgery options to offer. He recommends continuing treatment with Dr. Rampersaud. …show more content…
Shah to explain to Mr. Anderson since he always references "his original injury" and the swelling that he doesn't feel it was fixed. Dr. Shah told Mr. Anderson that he preformed the first surgery to repair the original injury that he did everything he could to repair that, there is no more surgery to offer. Mr. Anderson said he feels the injections and the benefit are being exhausted and he wants to try the spinal stimulator trial. Dr. Shah said he felt that was reasonable and we should talk with Dr. Rampersaud about that. The high dose of narcotics was discussed and Dr. Shah told Mr. Anderson that he has to reduce the dose. Mr. Anderson said he is worried that going to aqua therapy is going to increase his pain. I reminded him that he was able to drive to Florida and also walk on the beach and other tourist places, yes he had an increase in pain but he did it. Physical therapy will work on getting him stronger, he agreed. Dr. Shah said he is turning over his care to Dr. Rampersaud at this point. The current off work is until the next appointment with Dr. Rampersaud. We will be discussing the stimulator trial at that