DOI: 2/13/2015. The patient is a 48-year-old male driver who sustained a work-related injury after getting involved in a motor vehicle accident while making a delivery. Per OMNI entry, the patient has been diagnosed with head contusion and cheek/neck injury. MRI of the lumbar spine dated 05/22/2015 showed very small disc bulges and early facet arthropathy along the spine with very shallow posterior disc herniations at L3-4 and L5-S1, which causes no significant spinal canal and foraminal narrowing. Per the operative report dated 06/26/15, the patient underwent a lumbar transforaminal epidural steroid injection at the bilateral L5-S1 levels. Per medical report dated 07/13/2015, the patient stated that the injection helped but he is still …show more content…
He is taking pain medications, which do not help to take the edge off his symptoms. Pain is rated as 7/10 with medications. He states that his symptoms have not changed from his last visit. On examination of the lumbar spine, lordosis is decreased. There is tenderness of the paraspinal region at L5 bilaterally, and at the right sacroiliac joint. Active range of motion (ROM) shows flexion of 50 degrees and extension of 5 degrees, with pain. Motor strength shows 4/5 with right ankle dorsiflexion tibialis anterior and great toe extension extensor hallucis longus. Sensation is decreased over the lateral leg and dorsum of the foot. There is atrophy of the right calf. Current medications include gabapentin and Norco. IW was diagnosed with low back pain, lumbar disc annular tear, intervertebral disc annulus fibrosus tear, spinal facet joint arthropathy, lumbar discogenic pain. Treatment plan includes pain management referral and right L5-S1 Epidural Steroid Injection (ESI). Per verification to the PT facility, the patient has attended 2 PT sessions for the lower back from 04/22/15 through
An MRI was performed of the lumbar spine. The examination found no significant extra
Patient denies any complications and new complaints associated with epidural steroid injection procedure; however, he states that approximately 5 days after the injection procedure, he felt a sharp shooting pain down the posterior aspect of both legs to the feet to the feet when lying on his back with his feet on the floor. Otherwise, he reports ongoing axial lower back pain and weakness with no significant radicular symptoms at this time. He reports only mild relief with use of over-the-counter ibuprofen. In addition, he reports of moderate pain located at the low back which describes as an aching, continuous and sharp pain. He rated his pain as 5/10 in severity at the time of visit.
QEP Scripts for Two Recordings – Audio for Musculoskeletal System; “OK, Team! We have a new patient in Room 3B who is being admitted with a progressive (gradual, advancing) decrease in mobility (movement) of his back and legs, and increase in pain located in the lumbosacral (lower back above the tailbone of the spine) area. The patient’s Primary Care Provider has sent along Computed Tomography scans (CT, a rotating x-ray emitter, detailed internal scanner) showing spinal stenosis (narrowing of the spine causing pressure on the nerves and spinal cord causing lower back pain.) and decrease of the normal lordosis (abnormal curvature lower spine, excessive inward curvature of the spine) in the thoracic vertebrae (upper and middle back). Lumbosacral
Followup in one year to make sure he is not having any worsening of the strength or sensation of his extremities. I have advised him to contact me soon than this, though, should he have worsening of the strength or sensation of his extremities, especially of his distal lower extremities or other neurological difficulties before then. Thank you for allowing me to participate in this patient 's care, Craig Johnson,
Pain is located in the low back and left leg, rated as 4/10. There is associated numbness to the left thigh and foot, and pins and needles sensation to the left foot. He continues with Percocet with 80% help with use. CURES was very consistent and appropriate.
Per progress report dated 10/23/14 medicatiosn include Atenolol, Norco and cyclobenzaprine. Based on progress report dated 07/06/15, the patient presents with chronic right knee pain, described as dull and achy. Pain is worsened by sittlng,standing, and walking, and relieved by walking/exercise. He has been weaning norco and flexeril.
When the phenomenon affects the spine, may appear low back pain and
Reason for Visit: s/p ESI X 5 visits; Right Wrist Strain S: TM reports his right wrist pain at 0/10 with movement 4/10. His right wrist pain is caused by extension of his right, causing ganglion cyst to put pressure on the dorsal portion of the right wrist. TM describes this pain as "throbbing," with movement.
Medicare will cover chiropractic manipulation of the spine to correct a spinal subluxation that is demonstrated by physical examination or by x-rays. The patient must have a neuro-musculoskeletal condition resulting directly form the subluxation that requires treatment. The services provided must have a direct relationship to the patient’s condition. There must be a reasonable expectation of recovery or improvement of function. Maintenance therapy is not covered by Medicare.
A/P Andrew Strosahl is a 31-year-old male here today for several issues. Right shoulder pain. He reports that this pain has worsened with his activity recently. He is going to hold off on the yoga poses and the golf for now and try to give his shoulder a rest. I wrote him for naproxen 500 mg one p.o.
This pain stopped him from daily living activities such as driving, and also walking. A gait analysis was performed to find that he had an early heel rise on the left, and a short step length on the right. He had to have assistants from the rails to descend and ascend the stairs. Radiographs were performed and showed presence of retrocalcaneal exostoses.
Depending on your patient’s unique personal situation, you may find a certain neurosurgeon or orthopaedic spine surgeon to be more qualified to treat that patient’s specific
After the history and physical was completed, the patient was found to Bourchard’s and Hberden’s nodes. The 64 year old patient has been diagnosed with osteoarthritis. For the pain and stiffness, the patient was taking aspirin and Naprosyn which resulted in gastrointestinal (GI) distress. There are side effects and other consideration for determining the treatment.
1. Epigastric pain- In the past, the patient has had several back surgeries, has had chronic pain syndrome, and for a period of time, the patient has consumed opiate. In the two physical exams conducted in the office, the patient did not experience any abdominal pain. The patient nearly constantly had these abdominal pain episodes.
INTRODUCTION: Diffuse idiopathic skeletal hyperostosis (DISH) is an ossification of the vertebral body's anterior and lateral side (1,2). This is a rare entity and also known as Forestier’s disease, rarely associated with systemic diseases such as diabetes mellitus and obesity and occurs mostly in the fifth and sixth decade of life and in males (3). The osteophytes are usually seen in the thoracic, lumbar and cervical vertebrae (97%, 90%, 78%) (4). Most of patients are asymptomatic, dysphagia is the most common symptom due to compression of esophageus by anterior osteophytes at the level of C4-5.