Case Study Report For Ultracet
DOI: 6/17/2009. The patient is a 63-year-old male consulting utility employee who sustained a work-related injury to his cervical spine, bilateral shoulder and right knee after being involved in a motor vehicle accident.
As per progress report on 7/21/16, the patient presents for follow-up with ongoing neck and back pain. He continues to have frequent headaches, which have increased in intensity. He continues to report difficulty sleeping, which causes him to feel tired throughout the day.
His treatments have included cervical fusion at C5-6 in 2011 with relief, and interlaminar epidural steroid injection at C6-7 on 2/12/14 without relief. He has not tried physical therapy, chiropractic treatment or acupuncture.
His medications include Ultracet …show more content…
Ultracet also helps "calm down" his pain which helps decrease the occurrence of muscle spasms in his upper back. This then allows him to increase his daily activities such as washing the dishes or folding laundry without being in severe pain. Flexeril provides significant relief for muscle tension and spasms, it also helps his sleep better which allows him to feel more rested, the next day he has less pain. The patient does use the cream to help with soreness. He denies any side effects to these med1cat1ons.
In regards to the neck, the patient continues to report 5/10 pain that is worse on the left, radiates into the upper back, and causes muscles spasms.
He reports occasional pain down the left upper extremity to the hand. There is constant numbness and tingling in the first three digits of his left hand. He reports weakness in his left upper extremity which has caused him to drop things on occasion. Looking side to side, or repetitive movements will increase his pain.
In regards to the mid back, the patient reports 4/10 pain that is equal on both sides and radiates into his bilateral rib cage to the chest. He reports pain and difficulty with deep breaths on occasions. Coughing causes increased …show more content…
He has tenderness to palpation of the cervical and lumbar spine with spasms. Cervical range of motion includes 40 degrees of flexion, 10 degrees of extension, 30 degrees of right lateral bend, 35 degrees of left lateral bend, and 60 degrees of rotation on both sides. Spurling’s is positive on the left with symptoms to the back of the neck. Lumbar range of motion includes 30 degrees of flexion, 5 degrees of extension and 10 degrees of lateral bend on both sides. There is diminished sensation on the left C6 and C7 dermatomes of the upper extremities. He also has decreased sensation of the right L5 and S1. Motor strength is 4+/5 on the upper extremities. Strength is 2/5 on the right extensor hallucis longus and tibialis anterior. Right inversion strength is 4+/5. He has decreased S1 reflexes bilaterally. Spurling’s is positive on the
As per progress report on 7/21/16, the patient presents for follow-up with ongoing neck and back pain. He continues to have frequent headaches, which have increased in intensity. He continues to report difficulty sleeping, which causes him to feel tired throughout the day.
His treatments have included cervical fusion at C5-6 in 2011 with relief, and interlaminar epidural steroid injection at C6-7 on 2/12/14 without relief. He has not tried physical therapy, chiropractic treatment or acupuncture.
His medications include Ultracet …show more content…
Ultracet also helps "calm down" his pain which helps decrease the occurrence of muscle spasms in his upper back. This then allows him to increase his daily activities such as washing the dishes or folding laundry without being in severe pain. Flexeril provides significant relief for muscle tension and spasms, it also helps his sleep better which allows him to feel more rested, the next day he has less pain. The patient does use the cream to help with soreness. He denies any side effects to these med1cat1ons.
In regards to the neck, the patient continues to report 5/10 pain that is worse on the left, radiates into the upper back, and causes muscles spasms.
He reports occasional pain down the left upper extremity to the hand. There is constant numbness and tingling in the first three digits of his left hand. He reports weakness in his left upper extremity which has caused him to drop things on occasion. Looking side to side, or repetitive movements will increase his pain.
In regards to the mid back, the patient reports 4/10 pain that is equal on both sides and radiates into his bilateral rib cage to the chest. He reports pain and difficulty with deep breaths on occasions. Coughing causes increased …show more content…
He has tenderness to palpation of the cervical and lumbar spine with spasms. Cervical range of motion includes 40 degrees of flexion, 10 degrees of extension, 30 degrees of right lateral bend, 35 degrees of left lateral bend, and 60 degrees of rotation on both sides. Spurling’s is positive on the left with symptoms to the back of the neck. Lumbar range of motion includes 30 degrees of flexion, 5 degrees of extension and 10 degrees of lateral bend on both sides. There is diminished sensation on the left C6 and C7 dermatomes of the upper extremities. He also has decreased sensation of the right L5 and S1. Motor strength is 4+/5 on the upper extremities. Strength is 2/5 on the right extensor hallucis longus and tibialis anterior. Right inversion strength is 4+/5. He has decreased S1 reflexes bilaterally. Spurling’s is positive on the