Nursing Case Reports

DOI: 10/3/2001. Patient is a 68-year-old female clerk typist who sustained injury to her low back and left leg when she tripped on a hole. Per OMNI, the patient had chronic low back pain, sciatica, spondylolisthesis and spondylosis.
Per medical report dated 9/4/15 by Dr. Windham, the patient has done well with Cymbalta and Celebrex, and zolpidem for her trouble sleeping. She takes hydrocodone occasionally for breakthrough pain.
Based on the medical report dated 12/02/15, the patient presents for recheck of her back. She is long since P & S and is prone to flares and exacerbations. She has done well with Cymbalta and Celebrex, and she has zolpidem for her trouble sleeping which she takes infrequently. She also takes gabapentin 100 mg at bedtime for sciatica. She takes hydrocodone rarely for breakthrough pain. She was using a wheelchair until she restarted Cymbalta. She rates her pain level at 5-6/10.
She can walk on her heels and toes and still requires assistance. Straight leg raise is positive on the left. She flexes only 90 degrees and is limited by pain. Deep tendon reflexes are faint and symmetric at the knees and ankles.
Assessments are chronic low back pain, sciatica and lumbar spondylosis and spondylolisthesis.

Requested for recent progress report, however, no medical records received at the time of submission of the review to PA.
Per verification to the provider’s office, there is no available information if the IW has had a recent urine drug screen as they don’t perform this in their