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Examples Of Voluntary Observation Report

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Current subjective complaints (from claimant) and objective observations: Mr. Anderson continues to walk using 2 canes, his legs shake when he is walking; he has frequent tremors of his legs while sitting. Since having the permanent spinal cord implant done on 6/19/17 He reports that his pain has increased from the incision and to the right rib area. He is not able to sleep or get comfortable. He reports standing for more than 5 minutes is difficult. Said he was told to increase his Dilaudid and Percocet for 3 day by Dr. Shah but due to the level of pain he has he just continued with the increase dosage until the appointment with Dr. Rampersaud on 6/29/17.

Review of claimant’s stated pain/limitations: He continues to rate his pain at a 7 at best and up to a 10. Mr. Anderson said the pain interferes with all aspects of his life. It affects his sleep. Mr. Anderson said any activity increases back spasms. There is an increase in pain from the incision and right rib area for the implantation of the spinal cord device. …show more content…

Anderson was given printed information on the spinal cord pain stimulator device by Dr. Rampersaud.

MD visit details: On 6/29/17 I met Mr. Anderson at the office of Dr. Rampersaud. The permanent spinal cord stimulator was placed on 6/19/17. Mr. Anderson said since it was placed he has had an increase in right rib pain, incision pain and some shortness of breath. He reports that Dr. Shah told him to increase his medications for a few days. He said that since his pain was so severe he did not decrease the medications back down and is almost out of medications. He also reports he is not able to stand for very long, spending most of his time in bed.

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