Nursing Care Case Studies

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DOI: 4/24/2015. Patient is a 40-year-old female ophthalmic assistant who sustained a work-related injury to her low back and bilateral forearms from catching a falling cart. Per ONI entry, she was diagnosed with scoliosis, work aggravated. She is status post right shoulder arthroscopic acromioplasty and distal claviculectomy on 5/13/16.

Urine drug screen obtained on 10/06/16 showed positive for tramadol.
Per the Agreed Medical Re-evaluation report dated 11/17/16, the whole person impairment rating for the right shoulder is 8%. For the lumbar spine, IW is in a DRE Lumbar Category III. Future medical care for the right shoulder includes office visits, nonsteroidal anti-inflammatory drugs (NSAIDS), cortisone injections, home stretching/exercise program, PT/acupuncture and repeat diagnostic studies. For the lumbar spine, a repeat MRI is indicated.
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Current medications include Norco 5/325 mg 1 tablet daily and Zoloft 50 mg 1 tablet daily. It was noted that the IW has signed a treatment agreement for the prescription of controlled substances. Controlled Substance Utilization Review and Evaluation System (CURES) report checked on 11/29/16 was consistent with prescription history.
Based on the medical report dated 01/13/17, the patient complains of pain to her right shoulder and low back. Pain is described as sharp, stabbing, dull, achy and

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