Pain Management Case Study: A 55-Year-Old Patient

DOI: 1/25/2008. Patient is a 55-year-old male service technician who sustained a work-related injury when he slipped and fell while installing a tub. Urine drug screen dated 2/1/16 (no official result) revealed that the patient is consistent with the prescribed regimen. In a supplemental report on a pain management progress dated 6/20/16, the patient still has mild swelling and pain to be expected status post total left knee replacement. Diagnoses include hemarthrosis of knee or lower leg; hemarthrosis of left knee, lumbar facet arthropathy, bursitis of left shoulder, derangement of medial meniscus due to old tearing/injection of the left knee; and complete rupture of rotator cuff. As per office notes dated 7/18/16, the patient still has mild swelling and knee pain

Conservative treatment has been tried for more than 3 months but it failed. Pain scale is 10 without medications and 6 if with medications. There is 50% improvement with opioid medications. With medications, the patient is able to ambulate 5 feet as baseline and with medications, he is able to ambulate 100 feet. The location of pain is at the left knee, shoulder, and back pain. He describes it as aching, annoying, constant, intense, sore and tight. Recent hospitalizations notes that the patient had left knee surgery on 4/12/16. Physical examination revealed that he is shifting position in the chair frequently die to pain. He is tender over the upper thoracic spine. Impression notes that his left knee is healing well; he is scheduled to have physical therapy; and back pain is worsening. As per documentation of medical necessity for Norco. The patient notes that the pain is 7 before taking medication and that after taking the medication, the pain is decreased to a tolerable 5/10. He notes that without pain medication, he is unable to sit or stand for prolonged periods of time. Moreover, he is unable to work for any length of time without the medications. The pain also keeps him from being able to