ipl-logo

Low Back Pain Case Studies

934 Words4 Pages

This is a 47-year-old male with a 2/1/2007 date of injury, who injured his low back from lifting a large bucket of cut grass. DIAGNOSIS: 1. Left SI radicular symptoms. Lumbar discogenic pain with high-intensity zone at L5-S1 per MRI April 2007. X-ray showed 4-mm retrolisthesis at L5-S 1. 2. EMG/NCV studies consistent with peripheral motor and sensory neuropathies, from October 2008 12/15/15 Progress Report described that the patient has ongoing low back pain. He was last seen on 10/28/15. The patient stated that his current medication regimen has been helpful. He rated the pain 9/10-scale level, which is brought down to 6/10-scale level with the medications. The medications allow him to do his ADL. The patient also stated the Norco works …show more content…

This is a chronic pain patient and has been on Norco for an extended period of time.12/15/15 progress report described that that patient was on Butrans patch in the past and switched to Norco due to side effects of Butrans. The medications bring his pain to 6/10-scale level from 9/10-scale level. However, there remains little specific information regarding monitoring for diversion, dosage adjustments, functional improvement, attempts to wean and taper, endpoints of treatment and continued efficacy and compliance. Furthermore, there were no UDS or CURES reports available for review. A prior review from 05/08/15 denied Norco due to lack of documentation of continued efficacy, proper use of the medication, compliance; and absence of side effects and aberrant behaviors. The pharmacy list provided for review revealed that the last Butrans patch was approved on 09/11/15 and last Norco was approved on 05/02/15, however, the latest progress report contradicts this report. Current treatment regiment of the patient is unclear from the reports. Medical necessity of Norco 10/325 mg #60 has not been substantiated. Recommend non-certification. Non-certification here does not imply abrupt cessation for a patient who may be at risk for withdrawal symptoms. Should the missing criteria necessary to support the medical necessity of this request remain unavailable, discontinuance should include a tapering prior to discontinuing to avoid withdrawal

Show More
Related

L4-5 Nursing Case Studies

357 Words | 2 Pages

As per office notes dated 7/19/16, the patient complains of chronic low back pain at the localized curvature. There is radiating pain, which is increased since the fall. There is limited range of motion. Pain is exacerbated with walking, standing, and sitting. The patient had post lumbar surgery on August 2015.

Read More

Kwalon Case Summary

469 Words | 2 Pages

His medication regimens reported remain the same during this time, although compliance remained sporadic. According to Kwalon, he is now taking no medication. He struggled with behavioral and social difficulties most of his youth. He started smoking marijuana at age

Read More

Cmn 556 Unit 3 Journal Essay

611 Words | 3 Pages

My preceptor and I discussed both the dangers of this class of medications as well as their usefulness. We also discussed the fact that there is new research to

Read More

Pneumothorax Presentation

891 Words | 4 Pages

This article presents a case report about a 31 year old male patient, a teacher at a university, who started experiencing mid back pain after weightlifting one day.3 About 3 hours after weightlifting, the patient began to feel sharp back pain, at levels T4-T8. His pain began to worsen that night causing muscle spasms of his paraspinal muscles, with intermittent radiating pain to his lateral thorax and chest.3 This patient had been diagnosed with thoracic facet injuries in the past, and just assumed it was that.3 However, after the pain did not subside the patient went to his physician who claimed the patient was just having muscle spasms and needed myofascial release.3 However, a radiograph was also done that revealed end plate degenerative changes at T7-T8.3 The patients clinical evaluation revealed muscle spasms of the paraspinal muscles between T3-T12, tenderness to palpate between T6-T8, full shoulder ROM, 5/5 shoulder muscle strength, and normal distal pulses and sensations.3 The patient was diagnosed with thoracic pain and muscle spasms and was give muscle relaxants and exercises for myofascial release.3 Three days after the physician visit, the patient decided to do some walking, to work on his cardio, and experienced mild shortness of

Read More

Reconsideration-Disability Hearing Unit Case

323 Words | 2 Pages

Medical Records Information: Swollen lower extremities, tender to palpation lower back, right knee and left shoulder. Limited range of motion neck and lower back. Unable to squat, unable to walk on heels and toes. Asthma, sleep apnea, obesity (11/21/2014 weighed 304.4 pounds), diagnosed with rheumatoid arthritis. Was receiving mental health treatment for major depression and chronic pain in the lower back and legs, pain was “becoming intolerable.”

Read More

ICP Project: Pain Analysis

230 Words | 1 Pages

I understand the fears associated with adding more medication to an already heavily populated age group, but perhaps addressing the pain may assist with removal of other medications. I specialized in dementia for several

Read More

Bowel Case Studies

1465 Words | 6 Pages

It was noted that pain continues to be a major limitation for the patient. It was mentioned that better control over pain and spasticity since Baclofen pump placement, he continues to be highly motivated to continue physical therapies and his mood is buoyed by his meeting of physical

Read More

Wirach Case Study

892 Words | 4 Pages

Currently, he is prescribed Percocet with a maximum of eight tablets daily. He takes 1.5 tablets every six hours to help for his migraine headaches. His Percocet would start to decrease his pain after 30-45 minutes of ingestion, and the pain decreases for four hours. He mentioned that his pain never actually goes away. This medication was initiated three weeks ago.

Read More

Steroid Injection Case Study

362 Words | 2 Pages

It was also noted that the office will give a new lap slip. It was also noted that the patient is scheduled for a repeat caudal epidural steroid injection. Physical examination revealed that the cervical spine has decreased range of motion; tenderness to palpation at the paraspinal muscle; spasm at the bilateral cervical trigger point, bilateral trapezius rigger point, and bilateral rhomboid trigger point. There is also bilateral tenderness to palpation of facet joints C5-C7, positive Spurling’s test, foraminal compression test. Physical examination of the lumbar spine revealed decreased range of motion on all planes; tenderness to palpation at the lumbar paraspinous area; tenderness to palpation over the lumbar spine; bilateral straight leg raise; bilateral knee extension weakness, bilateral lumbar radicular sign, and spasm noted.

Read More

Jane Doe: A Case Study

352 Words | 2 Pages

The patient name is Jane Doe, with the diagnosis oof elbow pain of the right lateral epicondyle and lower back pain from an MVA that occurred in September of 2016. Jane Doe was hit from behind while waiting at a red light while holding onto the steering wheel. During the time of the MVA Jane Doe was currently in physical therapy for a previous MVA that occurred around September of 2015. In the MVA of 2015, Jane Doe complained of lower back pain. The MVA accident in 2016 increased the pain she was feeling in her lower back, and elbow pain started.

Read More

The Nursing Process Analysis

1215 Words | 5 Pages

Colombel et al (2010) provided that nurses are required to modify the planning process to the needs of individual patients and the implementation of MACROS can enable the nursing staff to ensure that plan is considering the measurability, achievability, realistic aspects, written results, and focused on the client. It was found that the pain of Allen was due to the causes leading to Crohn’s disease. The inflammation was planned to be treated with the intravenous hydrocortisone, which is the anti-inflammatory drug and prescribed for reducing the inflammation. Fisher et al (2008)further reflected that the initial doses of this planned drug are required to be forty to sixty grams on daily basis and she was prescribed for forty grams. Hill (2015) reflected that once the reduction in the pain is achieved the doses are reduced leading to

Read More

Pain Management Case Studies

802 Words | 4 Pages

CRNAs should always discuss DNR orders with the patient or their proxy prior to surgery especially since they were not part of the original discussion about resuscitation. Some hospitals have a policy to routinely suspend DNR orders prior to surgery, however this becomes a sensitive issue when dealing with hospice or palliative care patients presenting for surgery. Not all hospice patients have DNR orders, and likewise, just because a DNR order exists, should it blindly be followed when presenting to the OR? Scott & Garvin (2012) recommend that healthcare providers treat each DNR order individually versus following a universal hospital

Read More

Arguments Against Prescription Drug

505 Words | 3 Pages

My uncle recently finished a stay in rehab. His addition began with a prescription for Percocet for migraine headaches. In the beginning, he was very good and took them as prescribed.

Read More

Argumentative Essay On Adolescents And Antidepressants

1312 Words | 6 Pages

This pill is a more natural approach if the patient would not like to take the prescribed

Read More

Pain Assessment Essay

414 Words | 2 Pages

Many patients have difficulties in defining which response is best for their pain situation. (Spine, 2006) To provide ideal patient care, nurses require applicable information, skilled abilities, and new approaches toward pain assessment to help with control. Assessment information based on all available indications of pain assessment prevents patients from suffering. It is a crucial element in delivering effective pain management.

Read More

More about Low Back Pain Case Studies

Open Document