DOI: 7/27/2011. Patient is a 53-year-old female jobber who sustained a work-related injury to her lower back while she was throwing away a bad batch of buns and she felt a pop in her low back, causing numbness in her leg which gave out. As per OMNI notes, the patient also fell to the floor. Urine drug screen obtained on 12/17/15 is negative for hydrocodone and is positive for nordiazepam, Diazepam, oxazepam, temazepam, cyclobenzaprine, methamphetamine, and ethyl sulfate. Based on the medical report dated 01/06/17, the patient continues with neck and low back pain. She had a fall last week when her back spasmed and ended up cutting her foot. She notices that the cold weather is making the back pain more intense lately. The pain levels continue to go from as high as a 10/10 down to a 6/10 with Norco, and she wants to continue that and denies any negative side effects. She is not working. She is getting about 6 hours of poor quality of sleep at night. She has been doing some walking exercise. …show more content…
She has lumbosacral tenderness greater on the left. Patient Opioid Misuse Index score is 0/6, indicating the patient is not a potential misuser of opioids. Graded Chronic Pain Scale score shows current pain level of 8/10, and worst and average pain for the last 30 days is 9/10. Pain interference with ability work or housework is 10/10, with recreational, social and family activities is 7/10 and with daily or general activities is 6/10, for the last 30 days. Current medications include Norco 10/325 four tablets a day. Of note, last urine drug screen was obtained on