Your Name
BENZ, Ocala,AMY, FL
Overview
20
20
years of professional experience
Work History
01.2010 - Current
- This is a 53 year old female who: is being seen for a chief complaint of chronic low back pain involving the spine
- Context: having chronic back pain
- They are constant
- Quality: aching
- Severity is 7 out of 10 currently
- Is being seen for a chief complaint of follow up low back pain involving the spine
- Symptoms are aggravated by all movement
- They are constant
- Quality: aching and sharp
- Severity is 6 out of 10 currently
- Since the last visit, the status of the problem is unchanged
- Secondary Complaints include: The patient complains of thoracic spine pain
- The symptoms are 7 out of, Date Taken By B.P
- Pulse Resp
- O2 Sat
- Temp
- Ht
- Wt
- BMI BSA
07.2026 - 01.2024
- Patient presents today for follow-up regarding chronic axial mid back and lumbar spine pain
- Patient recently trialed on duloxetine, side effect of persistent nausea minimal relief to 90 with medication
- Patient request continued on this medication
- Patient is also previously trialed gabapentin and pregabalin discontinued those due to significant side effects
- Patient did have to reschedule her confirmatory bilateral T9/T10, T10/T11 thoracic medial branch block #2, this will be completed and was evaluated at her next office visit
- Patient gets significant pain relief from this we will consider radiofrequency ablation at the same level
- Patient currently takes hydrocodone 7.5 mg / 325 mg every 8 hours, as needed
- Approximately 70 to 80% pain relief when taking hydrocodone denies significant side effects
- UDS and PDMP are appropriate
- Patient also has been contacted by Zynex, her e-stim for her back pain should be shipping soon
- Today I have ordered a repeat thoracic and lumbar spine MRI due to patient's severe persistent spine pain.
Sex
Ocala, FL
01.2005 - 12 0
- Quality 134 (Screening for Clinical Depression and Follow-Up Plan): The patient was screened for depression and the screen was negative and no follow up required
- Additional Notes: PHQ2 depression screening administered, negative result found
- Note:
- Indra Ramdayal dnp
- Visit Note - September 20, 2024
- BENZ, AMY
- MRN:
- FPA561035
- Phone: (352) 414-9837
- DOB:, Female
- PMS ID:
- FPA561035
- Page 7Indra Ramdayal, NP (Primary Provider) (Bill Under) (352) 629-7011 Work (866) 592-7773 Fax
- PA Ocala 1910SW 18th Court, Indra Ramdayal, NP (Primary Provider) (Bill Under)
- Kathy Hicks
- Patient Referrals:
- Lumapas, Neal - Primary Care Provider (PCP)
- I have reviewed and agree with the findings of midlevel
- MIPS:
- Plan: MIPS Quality
- MIPS:
- Plan: MIPS Quality
- Spondylosis, Lumbar:
- Plan: Care timeline
- Thoracic Spine Pain:
- Plan: Prescription
- Long term (current) use of opiate analgesic:
- Plan: Morphine Milligram Equivalent, State Opioid Prescribing Database Reviewed, Counseling - Medication Monitoring, and Toxicology Review
- High Risk Medication Monitoring Narcotics:
- Plan: Toxicology Review
- Electronically Signed By: Jason Wei, MD, 09/21/2024 04:41 PM EDT, ID:
- FPA561035, FPA561035
- Page 3Indra Ramdayal, NP (Primary Provider) (Bill Under) (352) 629-7011 Work (866) 592-7773 Fax
- PA Ocala 1910SW 18th Court Suite #200
- Ocala, FL 34471
- Refill hydrocodone 7.5 mg 3 times daily as needed, FPA561035
- Page 4Indra Ramdayal, NP (Primary Provider) (Bill Under) (352) 629-7011 Work (866) 592-7773 Fax
- PA Ocala 1910SW 18th Court Suite #200, 34471
- Right Hip: FABER test: negative and FADIR test: negative
- Left Hip: FABER test: negative and FADIR test: negative
- T-Spine ROM: grossly intact
- L-Spine ROM: grossly limited and with pain
- Extension: limited and with pain
- Rotation to the right: limited and with pain
- Rotation to the left: limited and with pain
- Right Hip ROM:
- Flexion: 150 degrees
- Extension: 0 degrees
- Abduction: 45 degrees
- Adduction: 30 degrees
- Internal Rotation: 45 degrees
- External Rotation: 45 degrees
- Left Hip ROM:
- Flexion: 150 degrees
- Extension: 0 degrees
- Abduction: 45 degrees
- Adduction: 30 degrees
- Internal Rotation: 45 degrees
- External Rotation: 45 degrees
- Right Iliopsoas: Strength: 5/5, normal muscle tone
- Left Iliopsoas: Strength: 5/5, normal muscle tone
- Right Hip Abduction: Strength: 5/5, normal muscle tone
- Left Hip Abduction: Strength: 5/5, normal muscle tone
- Right Hip Adduction: Strength: 5/5, normal muscle tone
- Left Hip Adduction: Strength: 5/5, normal muscle tone
- Right Quadriceps: Strength: 5/5, normal muscle tone
- Left Quadriceps: Strength: 5/5, normal muscle tone
- Right Hamstring: Strength: 5/5, normal muscle tone
- Left Hamstring: Strength: 5/5, normal muscle tone
- Right EHL: Strength: 5/5, normal muscle tone
- Left EHL: Strength: 5/5, normal muscle tone
- Right Tibialis Anterior: Strength: 5/5, normal muscle tone
- Left Tibialis Anterior: Strength: 5/5, normal muscle tone
- Right Plantar Flexion: Strength: 5/5, normal muscle tone
- Left Plantar Flexion: Strength: 5/5, normal muscle tone
- Right Foot Eversion: Strength: 5/5, normal muscle tone
- Left Foot Eversion: Strength: 5/5, normal muscle tone
- Inversion: Strength: 5/5, normal muscle tone
- Inversion: Strength: 5/5, normal muscle tone
- RLE Dermatomal Sensation: normal to light touch throughout dermatomes
- LLE Dermatomal Sensation: normal to light touch throughout dermatomes
- RLE Peripheral Sensation: insensate to light touch throughout peripheral nerve distributions
- LLE Peripheral Sensation: insensate to light touch throughout peripheral nerve distributions
- RLE Reflexes: DTRs normal active LLE Reflexes: DTRs normal active
- Visit Note - September 20, 2024
- BENZ, AMY
- MRN:
- FPA561035
- Phone: (352) 414-9837
- DOB:, FPA561035
- Page 5Indra Ramdayal, NP (Primary Provider) (Bill Under) (352) 629-7011 Work (866) 592-7773 Fax
- PA Ocala 1910SW 18th Court Suite #200, 34471
- Right LE Pulses: normal posterior tibialis and dorsal pedis pulses, brisk capillary refill, no edema
- Left LE Pulses: normal posterior tibialis and dorsal pedis pulses, brisk capillary refill, no edema
- Data Reviewed:Review of the result(s) of each unique test (Toxicology Review (no))
- Impression/Plan:
- Spondylosis, Lumbar
- Problem Addressed: Stable chronic illness
- Spondylosis without myelopathy or radiculopathy, lumbar region (M47.816)
- Thoracic Spine Pain
- Problem Addressed: Stable chronic illness
- Pain in thoracic spine (M54.6)
- Plan: Prescription
- Hydrocodone 7.5 mg-acetaminophen 325 mg tablet PO
- Sig: One po Q 8 hrs as needed for non acute pain
- Quantity: 90 Tablet Earliest fill date: September 28, 2024 baclofen 10 mg tablet PO
- Sig: One tablet q 12 hours as needed for muscle spasms
- Quantity: 60 Tablet Earliest fill date: September 20, 2024
- Valium 5 mg tablet PO
- Sig: Bring tablet to procedure will be instructed on use
- Quantity: 1 Tablet Earliest fill date: September 20, 2024
- Long term (current) use of opiate analgesic
- Problem Addressed: Stable chronic illness
- Long term (current) use of opiate analgesic (Z79.891)
- Plan: Morphine Milligram Equivalent
- All conversion factors yield MILLIGRAM morphine equivalent
- Hydrocodone (mg/day): 21
- Morphine Milligram Equivalent per day: 21.00
- Plan: State Opioid Prescribing Database Reviewed
- The state database has been accessed and reviewed prior to prescribing a Class II and/or Class III controlled substance
- Plan: Counseling - Medication Monitoring
- Opioid Counseling
- Medication Counseling Other : Risks associated with long term use of opioids: Given the patients diagnosis and persistent chronic pain
- Treatment with opioid analgesic medication will likely be required for long term use
- At this visit I discussed the possible development of adverse-affects from the long-term use of opioids including: the development of physical tolerance to the medication, development of hyperalgesia and/or development of physical addiction
- I have further explained to the patient that any one adverse-affect may require either opioid rotation, tapering or discontinuation
- Safe use of Controlled Substance medication: The patient was instructed to take their controlled substance medication only as directed
- The patient was also advised not to consume any alcohol or illicit substances throughout the course of treatment with the controlled substance(s)
- The patient was asked to review the type of medication and instructions for administration at time of prescription pick-up from the pharmacy to confirm correct medication and instructions have been given
- The patient was also instructed on the potential side-affects that may occur with use of controlled substance(s) as well as signs of over medication
- If the
- Visit Note - September 20, 2024
- BENZ, AMY
- MRN:
- FPA561035
- Phone: (352) 414-9837
- DOB:, Female
- PMS ID:
- FPA561035
- Page 6Indra Ramdayal, NP (Primary Provider) (Bill Under) (352) 629-7011 Work (866) 592-7773 Fax
- PA Ocala 1910SW 18th Court Suite #200
- Ocala, 34471 patient were to develop any slurred speech, dizziness, confusion, excessive drowsiness, trouble breathing, skin pallor, or difficulty waking from sleep he/she was advised to discontinue use of the controlled substance medication and to call the office or visit the emergency room
- Safe storage of Controlled Substance medication: The patient was instructed that all controlled substance medications should be stored in their original bottles inside a locked cabinet, lockbox or a location where others cannot easily access them.
09.2020
- 2435
- Hicks, Kathy 128/84
- SIT69.0 in 250.0 lbs9 2.3
- FiO2
- Patient Reported
- Care timeline
- Management history log
- Summary: patient is here for follow-up visit, patient has been seen by Dr
- Shetty
- Status post bilateral L4-L5 transforaminal ESI on February 20, 2024 with Dr
- Wei, greater than 80% relief for radiating pain to the right side anterior rib cage
- Her main complaint is of right side of thoracic spine MRI her main complaint is right side of thoracic spine
- T9-T12, she has tried ice, heat, NSAIDs, she is currently on physical therapy
- She is having radicular pain to right cage and right flank from right side of thoracic spine
- Her pain level is 8 out of 10 and pain is intensifying
- She is not able to stand or sit for longer than 5 minutes
- 28/2024
- Patient presents today for follow-up visit regarding her chronic axial mid back pain and her chronic low back pain
- Patient longstanding patient with Dr
- Shetty manage for her low back pain
- She is status post several lumbar L4/L5, L5/S1 transforaminal epidurals with variations of those over the years with Dr
- Shetty, patient reports transient relief with these injections with 1 injection lasting approximately 1 week
- Patient's status post bilateral T9/T10, T10/T11 thoracic medial branch block #1 4/30/2024 patient reports significant swelling at the injection site after the procedure but reports 80% pain relief for duration of anesthetic
- We will proceed with the additional trial injection if that is successful we will plan for RFA at these levels
- Patient currently taking hydrocodone 7.5-325 milligrams, every 8 hours, for her chronic low back and mid back pain
- Patient reports approximately 80% pain relief for the duration of the medication which allows her to increase her mobility and complete her ADLs
- She has previous taken gabapentin, pregabalin, in the past, discontinued due to side effects
- UDT consistent
- PDMP reviewed and consistent
- Patient has completed several rounds of physical therapy for her mid back pain, patient states that the physical therapy itself was marginal in benefit but the commercial grade e-stim machine that was used on her mid back did provide great relief for her chronic thoracic spine pain
- Today I have ordered a Zynex estim device to be used for patient's chronic mid back pain in addition to the interventional procedures
- Visit Note - September 20, 2024
- BENZ, AMY
- MRN:
- FPA561035
- Phone: (352) 414-9837
- DOB:
08.2026
- 24
- S/p Bilateral Levels: T9-T10 and T10-T11 MBB #2, 8/6/24, reporting >80% pain relief x 24 hrs
- Discussed to Schedule RFA T-spine with Dr
- Wei
- Completed lumbar and thoracic spine
- Discussed findings with patient and plans for future intervention post MBB/RFA T-spine procedure
- Current regimen helping tolerable pain relief
- No adverse side effects
- Previous UDS 7/26/2024 + hydrocodone consistent
- PDMP consistent
- Plan
- Bilateral Levels: T9-T10 and T10-T1 RFA
- Refill med
- Follow-up in 1 month20/2024
- Schedule rfa
- Order diazepam 5 mg x1
- Patient has myofascial pain and swelling
- Plan Due to multi level pain thoracic radiation
- Order consult with Dr
- Freeman Review multiple imaging Pdmp 8/29/2024 hydrocodone 7.5/325 #90 Udt 8/6/2024 hydrocodone and metabolitesbaclofen 10 mg q12 hours as needed.otc medications
- Procedures/surgery:
Adjunct
01.2012
- Right Tri mall fracture with ORIF
- Previous management: previous therapies:, events: Gabapentin, pregabalin–stopped both due to side effects, Topamax–discontinued due to severe side effects
- NSAIDs: Previous treatment with meloxicam, meloxicam, Voltaren, Aleve, naproxen–patient reports feeding therapy with these medications
- Muscle relaxants: Flexeril, tizanidine, baclofen–fleeting response with these medications
- Other:
- Plan
- Meds:
- Visit Note - September 20, 2024
- BENZ, AMY
- MRN:
- FPA561035
- Phone: (352) 414-9837
- DOB:
Skills
- Mcg/actuation Nasal -
- Spray,suspension
- Amlodipine 5 mg Oral - tablet
- Celecoxib 200 mg Oral - capsule
- Cyclobenzaprine 10 mg Oral -
- Tablet
- Duloxetine 20 mg Oral - Dose: 1
- Capsule capsule,delayed
- Release (ec) Frequency: Once
- A day
- Hydrocodone-acetaminophen
- 75-325 mg Oral - tablet
- Hydroxyzine HCl 10 mg Oral -
- Losartan 25 mg Oral - tablet
- Meloxicam 15 mg Oral - tablet
- Rosuvastatin 10 mg Oral - tablet
- Tizanidine 2 mg Oral - tablet
- Medical History
- Reviewed August 26, 2024
- Chronic pain
- Fatigue
- Gastroesophageal reflux
- Disease
- H/O: depression
- H/O: varicose veins
- Headache: Migraines
- Hernia: hiatal
- History of urinary tract infection
- Hypercholesterolemia
- Insomnia
- Obesity
- Sleep apnea
- Other: High Blood Pressure
- Urinary Incontinence
- Interventional Pain
- Musculoskeletal
- History
- Chronic low back pain
- Fracture of ankle
- H/O: arthritis
- Neuropathy
- Sciatica
- Spinal stenosis of lumbar region
- Family History
- Diabetes
- Hypertension
- Osteoarthritis
- Osteoporosis
- Scoliosis
- Chief Complaints:
- Chronic Low Back Pain1
- Follow Up Low Back Pain2
Accomplishments
- T spine and L spine MRI
- Procedure: Bilateral T9/T10, T10/T11 thoracic medial branch block #2 with Dr
- Wei
- If successful we will consider RFA at these levels
- HEP: yes lumbar
- RTC: 4 weeks
- Findings:
- General Appearance
- Appearance: overweight, well developed, and well groomed
- Orientation: Alert and oriented to person, place, time
- Mood: mood and affect well-adjusted, pleasant and cooperative, appropriate for clinical and encounter circumstances
- T-spine
- T-Spine ROM: Moderate to severe tenderness midline and Right > Left PV area of the mid thoracic spine
- T-Spine Inspection: kyphoscoliosis, left paraspinal musculature tender to palpation, right paraspinal musculature tender to palpation, and midline tenderness
- TL-Spine and Hip
- Gait: mildly antalgic
- Upper Trunk Skin Inspection: skin intact, no rashes or lesions
- Lower Trunk Skin Inspection: skin intact, no rashes or lesions
- T-Spine Inspection: no paraspinal musculature tenderness and no scoliosis
- L-Spine Inspection: left and right paraspinal musculature tender to palpation
- Posture: lumbar hypolordosis: mild
- Inspection:
- Right Hip: no trochanteric tenderness
- Inspection:
- Left Hip: no trochanteric tenderness
- L-Spine Stability: No bony step-off, no gross deformity, normal sagittal and coronal alignment
- Thoracolumbar Spine Special: FABER test: negative on the left, FABER test: negative on the right
- Facet Loading test: positive to the left, Facet Loading test: positive to the right, Facet Loading test: positive to extension, Right SLR ipsilateral pain: negative, Left SLR ipsilateral pain: negative, and
- Waddell's test: negative
- Special: Special:
- Visit Note - September 20, 2024
- BENZ, AMY
- MRN:
- FPA561035
- Phone: (352) 414-9837, REASON > 72 HOUR RX GIVEN: Based on the patient’s chronic non-malignant pain, a prescription for greater than a 72-hour supply of opioid analgesic medication is being prescribed today
- The patient will require chronic long-term treatment with an opioid analgesic to facilitate a reduction in the patient’s pain level as well as to maintain adequate physical function
- PDMP reviewed at this visit
- At this visit we discussed and reviewed the non-opioid and non-narcotic alternatives including but not limited to physical therapy, interventional pain procedures, and NSAIDS, if appropriate
- The patient was provided with the information on Nonopioid Alternative for the Treatment of Pain Pamphlet
- Plan: Toxicology Review
- Specimen Type: Urine
- The following confirmation positive results were found: Hydrocodone and Norhydrocodone
- Patient Specific Counseling: REV OF UDT 7/24/2024 hydrocodne and metabolites AND PDMP SHOWS COMPLIANCE
- Patient Specific Counseling: -
- High Risk Medication Monitoring Narcotics
- Problem Addressed: No MDM
- Long term (current) use of opiate analgesic (Z79.891)
- Associated diagnosis: Encounter for therapeutic drug level monitoring (No MDM)
- Plan: Toxicology Review
- The state database has been accessed and reviewed prior to prescribing a Class II and/or Class III controlled substance
- Urine drug screening is being ordered today to assess compliance with prescribed medications and identify common prescribed and non-prescribed substances that can impact medical efficacy and patient safety
- Based on the reason(s) indicated in the completed scanned in lab requisition form, a Definitive Test will also be ordered
- Date of Toxicology Testing: 07/26/2024
- Specimen Type: Urine
- Patient Specific Counseling: -
- The following POC positive results were found: Opiates/Morphine
- The following POC negative results were found: Amphetamines, Cocaine, Marijuana, and Methamphetamine
- The following POC normal results were found: Bleach, Creatinine, Nitrate, pH, and Specific Gravity
- MIPS
- MIPS
- Plan: MIPS Quality
- Quality 317 (Preventative Care and Screening: Screening for High Blood Pressure and Follow-up Documented): Elevated or hypertensive blood pressure reading documented, and the indicated follow-up is documented
- Additional Notes: The patient is referred to their PCP and educated regarding hypertension
- MIPS
- Plan: MIPS Quality.
Interests
DOB:
, 05/19/1971
Sex:
Female,
Driving status:
, Drives in the Daytime
Drives at Night
Additional Information
- PMS ID: , FPA561035
Timeline
08.2026
07.2026 - 01.2024
09.2020
Adjunct
01.2012
01.2010 - Current
Sex
01.2005 - 12 0