Back Pain Case Summary
DOI: 6/25/2013. Patient is a 39-year old male commercial driver who sustained injury while he was parked when he got struck from behind by a tractor trailer. Per OMNI, he suffered injury to his neck, back, shoulders, elbows, and knees. He is out of work since the date of injury. He is status post cervical discectomy with fusion at C4-6 on 3/12/14 and a suboccipital craniotomy and decompression of a C1 lamina due to Chiari malformation on 12/29/14.
Per medical report dated 06/30/15, patient presented for low back pain with left anterior leg pain. He has not tried PT or injections. He does have weakness in the left leg. At times, he is unable to put pressure on the left side. He does have numbness/tingling.
On examination, motor strength in
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He has ongoing progressive back pain with numbness, pain and weakness in the left leg/foot and occasionally on the thigh. He has done physical therapy, but he would now like a definitive plan. Recommendation was made for a L4-5 decompression and fusion. He will need complete facet resection in order to alleviate that lateral recess stenosis, as well as a likely decompressive laminectomy at L3-4 and L5-S1. In the meantime, he was advised to continue physical therapy and home exercises.
Based on the medical report dated 09/01/15, the patient was recommended to undergo a lumbar surgery. He presented for a medication refill of Norco 10/325 in conjunction with Flexeril and Meloxicam.
On examination, he ambulates in a slightly antalgic fashion into the examination room, favoring his left lower extremity. Motor strength with bilateral hip flexion against resistance is rated as 4+/5, extension and retraction of bilateral lower extremities rated as 4/5 on right and 4-/5 on the left and dorsiflexion/plantar flexion of left lower extremity rated as 4/5 and to the right as 4+/5. Sensation to light touch displays hypoesthesia along the left lower extremity. He was assessed to have a lumbar spondylosis.
Per the IME report dated 07/23/15 by Dr. Kercull, IW was diagnosed with herniated d lumbar disc to the left including the L4 nerve
Orleda Lee Harris Case Summary
302 Words | 2 PagesAn MRI was performed of the lumbar spine. The examination found no significant extra
Nursing Case Memo
647 Words | 3 PagesDOI: 4/16/2012. Patient is a 29-year-old male technician who sustained injury when he was 25-feet up on a ladder when the ladder slid and he fell onto the pavement. He had an open reduction internal fixation (ORIF x 2) for a compound tibia fibula fracture and had hardware removal in 4/25/2013. MRI of the lumbar spine performed on 3/24/2016 revealed L5-S1 small right paracentral disc protrusion without significant spinal canal stenosis or neuroforaminal narrowing.
Low Back Pain Case Studies
934 Words | 4 PagesThis is a 47-year-old male with a 2/1/2007 date of injury, who injured his low back from lifting a large bucket of cut grass. DIAGNOSIS: 1. Left SI radicular symptoms. Lumbar discogenic pain with high-intensity zone at L5-S1 per MRI April 2007. X-ray showed 4-mm retrolisthesis at L5-S 1.
Room 3b Case Study
859 Words | 4 PagesQEP 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
Jimmie Bowman Case Study
362 Words | 2 PagesFollowup 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,
Percocet Case Summary
284 Words | 2 PagesDOI: 5/19/2010. Patient is a 57-year-old male electrician who sustained injury when he was struck in the back by a car in a parking lot. He underwent a L5 laminectomy and decompression of the neutral elements 2011. Per the progress report dated 5/18/16, the patient complained of low back and left leg pain.
Iw Case Studies
312 Words | 2 PagesRange of motion is limited with flexion and extension of 20 degrees limited by pain. Spurling test is positive. Sensation is diminished C5-C6 bilaterally. Diagnoses are cervical strain, bilateral C5-C6 cervical radiculopathy, and diminished sensation, C6 reflex bilaterally.
Left Wrist Case Summary
247 Words | 1 PagesDOI: 7/28/2014. Patient is a 33-year old male laborer who sustained injury when his left wrist twisted and snapped while using a drill. Per OMNI, he was initially diagnosed with dislocation of the left wrist. He underwent a tendon graft reconstruction on 08/07/14 and hardware removal on 09/11/14.
Iw Case Report
635 Words | 3 PagesDOI: 5/22/2000. Patient is a 52-year-old female stitcher operator who sustained injury while she was pushing load onto a stitcher when she strained her right shoulder, wrist elbow, and neck. She underwent exploration of cervical fusion at C5-T7 with anterior cervical discectomy with fusion at C3-C5 on 12/13/11 and implantation of new implantable pulse generator (IPG) and spinal cord stimulator unit on 09/17/14. Based on the latest medical report dated 01/29/16, the IW presents for follow up of neck and shoulder pain.
Iw Case Reports
566 Words | 3 PagesDOI: 6/25/2007. Patient is a 37-year-old female store manager who sustained injury when a tote slipped off shelf and struck her left side of the body. Per OMNI, she is status post ulnar nerve decompression on 03/11/08, left De Quervain’s release on 09/08/09, spinal cord stimulator implant on 08/03/11 and shoulder surgery on 01/19/15. Per the PT attendance report dated 05/07/15, the IW has attended a total of 30 sessions for the left shoulder from 02/05/15 through 05/01/15.
Left Knee Case Summary
883 Words | 4 PagesThere were scars noted on both knees. He can flex knees to about 120 degrees. Treatment plan: Suboxone and UDS/CURES. Discussion: The first step would be to decrease the pain in the knee.
Work Related Injury Case Study
256 Words | 2 PagesThe pain is alleviated by lying down. He has not been able to go to the gym for the past two months due to increased pain. On examination, there is tenderness on the left subtalar region.
Carpal Tunnel Syndrome Summary
286 Words | 2 PagesPer medical report dated 06/16/2015 by Dr. Lemley, the patient complains of pain and dysfunction to bilateral hands/wrists. She has right greater than left discomfort in her thumbs with numbness. She states that cortisone injections do not help.
Carpal Tunnel Syndrome Case Summary
388 Words | 2 PagesDOI: 07/27/2006. Patient is a 36-year-old female apprentice engineer who sustained an injury to her neck and back due to lifting of hall demolition debris. Per OMNI entry, she is diagnosed with chronic back sprain/strain. Urine drug screen obtained on 04/05/16 revealed positive for hydrocodone and Flexeril.
Examples Of Voluntary Observation Report
309 Words | 2 PagesSaid he was told to increase his Dilaudid and Percocet for 3 day by Dr. Shah but due to the level of pain he has he just continued with the increase dosage until the appointment with Dr. Rampersaud on 6/29/17. Review of claimant’s stated pain/limitations: He continues to rate his pain at a 7 at best and up to a 10. Mr. Anderson said the pain interferes with all aspects of his life. It affects his sleep. Mr. Anderson said any activity increases back spasms. There is an increase in pain from the incision and right rib area for the implantation of the spinal cord device.
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