Introduction to Maria In Her Own Words
Maria’s Chart
HPI
Maria is a 31 year old Hispanic female with a five year history of lower back pain with intermittent radiculopathy complicated by an approximately two year history of opioid use disorder (OUD). She is currently in recovery and takes buprenorphine / naloxone (bup/nal) 8mg / 2mg sublingual films once daily. She attends weekly Narcotics Anonymous meetings in addition to receiving medications for opioid use disorder (MOUD). She presents today for assistance with her back pain.
Substance Use History
Maria describes use of heroin, and possibly fentanyl, for 6-7 months via nasal insufflation. During this time she describes inability to quit or decrease use, despite an episode of overdose requiring resuscitation via intranasal naloxone. Intake progressively increased due to tolerance. She lost her job as a line cook during this time as well as separated from a long-term romantic partner. Withdrawal symptoms, when present, were disabling and consisted primarily of diarrhea, abdominal cramping, myalgia, anxiety, and cold sweats. She states she still has intermittent cravings, especially when exposed to significant life stressors.
Pain Assessment
- Severity
- Now 6/10, Average 6.5/10, Worst 10/10, Least 3/10
- Interference
- Activity 8/10, Mood 7/10, Walking 9/10, Normal Work 8/10, Relationships 5/10, Sleep 10/10, Enjoyment 7/10
- Descriptors
- Sharp, squeezing
- Timing
- Present upon awakening with increased severity throughout the day
- Radiation / Location
- Bilateral pain in lumbar region with intermittent radition
- Alleviating
- Bracing at work, bup / nal (for short periods)
- Aggravating
- Reaching, bending over, lifting
- Trialed modalities
- Physical Therapy (helps while there), Epidural Injections X 2 (helps for approximately 24 hours). Denies trials of topical modalities, transcutaneous electrical nerve stimulation, or acupuncture.
- Exercise
- Endorses occasional stretching and exercises but admits could do more regularly
Past Medical History
- Nonspecific chronic low back pain
- Opioid Use Disorder
Past Surgical History
None
Medications
Current Medications
- Bup/nal sublingual films 8mg/2mg: One film sublingually once daily in the morning
- Ibuprofen 600mg tablets: One tablet by mouth every 8 hours as needed with food
- Ethinyl estradiol / norgestimate (Ortho Tri-Cyclen Lo): One tablet by mouth once daily
Previous Medications
- Tramadol 50mg tablets: One tablet by mouth twice daily as needed (3 years ago for 2 months)
- Naproxen 500mg tablets: One tablet by mouth twice daily as needed (4 years ago for 12 months)
Social History
- Tobacco – ½ pack per day, cigarettes
- Alcohol – 1 or 2 glasses of wine after work one night per week
- Recreational Drugs – denies
- Diet – none
- Caffeine – 2 cups of coffee daily, several caffeinated sodas at work
- Work – line cook and waitress at restaurant
Family History
- Mom (age 56), unremarkable
- Father (age 59), unknown
- Sister (age 26), OUD, PTSD
Review of Systems
- HEENT
- Denies, HA, visual changes, cough
- CV/PULM
- Denies CP/SOB, palpitations, wheezing
- GI/GU
- Denies N/V/D/C, urinary retention or urgency
- Ext
- Denies swelling
- Neuro
- Denies saddle anesthesia, worsening radicular symptoms or LE numbness
- CNS
- Denies SI/HI
Physical Exam
- Vitals
- Height – 64 in, weight – 115 lbs, temp – 97.6 F, heart rate - 82 bpm, respiratory rate – 16 bpm, O2 saturation – 99%
- Gen
- WDWN, normal affect, A&O X 3, NAD
- HEENT
- PERRLA, EOMI
- CV/PULM
- RRR, no m/g/r, lungs CTA
- GI
- Decreased bowel sounds, no guarding or rebound tenderness
- GU
- Deferred
- Ext
- No c/c/e, normal turgor
- MS
- Normal ROM, negative SLR, negative FABER
- Neuro
- Normal gait & station, CN II-X grossly intact, DTR 3+, no drop foot
Maria’s Chart
Laboratory Values
(From last office visit 1 month ago.)
| Lab | Reference Range | Result |
|---|---|---|
| Hemoglobin (g/dl) | 12-16.5 | 12 |
| Hematocrit (%) | 36-50 | 34 |
| RBC (x 106/ml) | 4-5.5 | 4.2 |
| WBC (x 103/mm3) | 4-10 | 9.4 |
| Platelet count (x 103/uL) | 100-450 | 225 |
| Sodium (mEq/L) | 135-147 | 139 |
| Potassium (mEq/L) | 3.5-5.2 | 4.2 |
| Chloride (mEq/L) | 95-107 | 100 |
| CO2 (mg/dL) | 20-29 | 21 |
| BUN (mg/dL) | 7-20 | 12 |
| Creatine (mg/dL) | 0.5-1.4 | 1.0 |
| Glucose (mg/dL) | 64-128 | 86 |
| HgbA1c | 5.3% | |
| TSH | 0.4-4 mIU/L | 2.7 |
Urine Drug Testing (GC-MS)
Drugs present:
- Hydrocodone 45 ng/mg creat
- Hydromorphone 79 ng/mg creat
- Dihydrocodeine 32 ng/mg creat
- Norhydrocodone 211 ng/mg creat
- Buprenorphine 186 ng/mg creat
- Norbuprenorphine 441 ng/mg creat
- Ibuprofen 72 ng/mg creat
- Creatinine 227 mg/dL
Testing
- Lumbar spine Axial CT with sagittal and coronal reconstructed images
- Evidence of facet arthropathy at L4, L5.
- Broad based disc bulge at L5/S1 resulting in mild left neuroforaminal narrowing and mild right neuroforaminal narrowing.
- No evidence of central canal involvement at any level.
- No evidence of spondylosis or spondylolisthesis at any level.
- PHQ-9: 14
- GAD-7: 9
