DOI: 10/14/2009. The patient is a 44-year old female hospital medical records clerk who sustained a work-related injury after tripping over garbage can and fell on her right knee on 02/07/2010.
Based on the medical report dated 08/19/16, the patient complains of 7/10 pain to her lower back, left knee, right knee and right ankle. The pain radiates to the left leg and right leg.
Of note, she had surgery on the right knee to drain fluid in 2010, 2012, and 2014. She had left knee meniscus repair in April 2016. She had some physical therapy for her knees, facet joint injections to her low back and a radiofrequency ablation that offered little relief.
Her condition is associated with back pain, difficulty in ambulation, joint swelling, numbness, …show more content…
Patient has been experiencing depressive symptoms. Patient states that she gets upset very easily, tends to worry a lot and get irritated. She shows diminished interest in day to day activities. Patient is having sleepless nights nearly every day. She has shown lack of concentration while doing skilled work. She feels fatigued and complains of reduced energy. Patient endorses feelings of helplessness, hopelessness and worthlessness.
Current medications include Norco, Nucynta, alprazolam and duloxetine.
IW was diagnosed with the following: intervertebral disc disorders with radiculopathy, lumbosacral region; osseous and subluxation stenosis of intervertebral foramina of lumbar region; other intervertebral disc degeneration, lumbosacral region; and pain in the bilateral knees.
Plan is for psychiatric consult to manage patient's depression and anxiety secondary to her industrial injury. Patient was previously given medications.
It was noted that the patient has chronic pain syndrome. Patient reports loss of function that has persisted beyond three months and has evidence excessive dependence on health-care providers, spouse, or family. IW reports secondary physical deconditioning due to disuse and/or fear-avoidance of physical activity due to pain. Patient has failed to restore preinjury function after a period of
Based on the medical report dated 08/19/16, the patient complains of 7/10 pain to her lower back, left knee, right knee and right ankle. The pain radiates to the left leg and right leg.
Of note, she had surgery on the right knee to drain fluid in 2010, 2012, and 2014. She had left knee meniscus repair in April 2016. She had some physical therapy for her knees, facet joint injections to her low back and a radiofrequency ablation that offered little relief.
Her condition is associated with back pain, difficulty in ambulation, joint swelling, numbness, …show more content…
Patient has been experiencing depressive symptoms. Patient states that she gets upset very easily, tends to worry a lot and get irritated. She shows diminished interest in day to day activities. Patient is having sleepless nights nearly every day. She has shown lack of concentration while doing skilled work. She feels fatigued and complains of reduced energy. Patient endorses feelings of helplessness, hopelessness and worthlessness.
Current medications include Norco, Nucynta, alprazolam and duloxetine.
IW was diagnosed with the following: intervertebral disc disorders with radiculopathy, lumbosacral region; osseous and subluxation stenosis of intervertebral foramina of lumbar region; other intervertebral disc degeneration, lumbosacral region; and pain in the bilateral knees.
Plan is for psychiatric consult to manage patient's depression and anxiety secondary to her industrial injury. Patient was previously given medications.
It was noted that the patient has chronic pain syndrome. Patient reports loss of function that has persisted beyond three months and has evidence excessive dependence on health-care providers, spouse, or family. IW reports secondary physical deconditioning due to disuse and/or fear-avoidance of physical activity due to pain. Patient has failed to restore preinjury function after a period of