DOI: 6/2/2011. Patient is a 49-year-old female phlebotomy technician who sustained a work-related injury to her left shoulder when she was struck by a fellow worker. Patient is status post left shoulder superior labrum anterior and posterior repair, decompression, and resection of the left distal end of the clavicle on 1/31/2011.
Urine drug screen obtained on 03/25/16 showed positive for tramadol, desmethyltramadol and acetaminophen.
As per the medical report dated 12/7/16, patient has a migraine. She is pending cervical surgery. She has discomfort described as sharp, aching, burning, severe, continuous, pain, varying with activity, increasing with movement, tightness, and throbbing. She rated the discomfort as 9/10 without medications and
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With the use of Fioricet, it brings migraine pain down to a 7/10 and without the Fioricet, a 9/10. Imitrex worked better for her migraines (9->4), but apparently hasn't been approved in several months.
Her discomfort was described as sharp, aching, burning, shooting, severe, continuous, pain, discomfort, varying with activity, increasing with movement, tightness and throbbing. The symptoms become aggravated by almost any movement, lifting, pulling, carrying, reaching, twisting, turning, bending, running, jumping, driving, cleaning, gardening, cooking, repetitive motions, bending for long periods of time, carrying groceries, household chores, lifting children and yard work. The symptoms are reduced by taking medications, applying ice /heat compresses, transcutaneous electrical nerve stimulation (TENS) unit and massaging.
Physical examination is essentially unchanged. Spinal restrictions/subluxations are noted at T1-12 and L1-L5.
Pain/Tenderness is noted over the upper to mid/mid to lower cervical, cervico-thoracic, upper/mid/lower thoracic, thoraco-lumbar, upper/lower lumbar and lumbo-sacral and left shoulder.
Of note, Controlled Substance Utilization Review and Evaluation System (CURES) report was reviewed.
Patient was diagnosed with lumbar pain, thoracic pain, and left shoulder