57-Year-Old Male Bookbinding Operator's Injury Of Di

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DOI: 08/29/2006. Patient is a 57-year-old male bookbinding operator/route salesman who sustained injury when he was startled by a cat while making a delivery and fell. Per OMNI, he was initially diagnosed with lumbar herniated disk. The patient is currently temporary totally disabled due to knee surgery in April 2013. Based on the progress report dated 03/21/16, the patient reports that his low back pain tweaked again, after making the bed. He went to the emergency room last week and was provided with Toradol injection. He was told it was sciatica on the right leg. Now, it is in the center of the back and sacroiliac area. Current pain level is 8/10 with pain medications. He also reports that the left side of the back and leg is aggravated by sitting between 1 to 1.5 hours. On examination of the back, there is tenderness upon palpation midline of the lower lumbar and sacral region. Posture shift is to the left.…show more content…
Assessments include myositis, low back pain, thoracolumbar and lumbosacral intervertebral disc disorder, muscle spasm of the back and lumbar radiculopathy. He was given a prescription for Flexeril and Toradol. Toradol 60 mg injection was performed on this visit for low back pain. Current request is for 30 Tablets of Flexeril with 3 Refills between 3/28/2016 and

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