DOI: 5/19/2010. Patient is a 57-year-old male electrician who sustained injury when he was struck in the back by a car in a parking lot. He underwent a L5 laminectomy and decompression of the neutral elements 2011. Per the progress report dated 5/18/16, the patient complained of low back and left leg pain. Percocet decreases pain by 80% and enables him to perform light gardening and household chores. No side effects with Percocet use. He is doing well with current medications and is compliant with no aberrant behavior. Upon lumbar examination, motion is associated with increase in pain. Left seated straight leg raise is slightly positive. There is decreased sensation of the left anterior thigh. He has forward leaning stiff gait with ability for heel and toe rise. …show more content…
Pain is located in the low back and left leg, rated as 4/10. There is associated numbness to the left thigh and foot, and pins and needles sensation to the left foot. He continues with Percocet with 80% help with use. CURES was very consistent and appropriate. Review of systems is positive for heat/cold intolerance, skin rash, new growth or mole, snoring, ankle swelling, abdominal pain, nausea, muscle pain, muscle weakness and difficulty sleeping. As of this report, an 11-panel urine drug screen was administered on this visit and showed positive for oxycodone. Patient continues with failed back and radicular pain for several years and failing adjuvant and increasing tolerance. A second opinion was advised and proceed with surgery if needed, or a trial of spinal cord stimulator. Current request is for 150 Tablets of Percocet 10/325 mg between 6/20/2016 and