His doctor recommended the applicant to have acupuncture and physical therapy. He said that there has not been any discussion of surgeries or injections. He takes Naprosyn three times a week. He claims that he began having radiating pain into his knee since he started treating at Southland Spine. He claims this pain occurs three times per month.
Page’s patient, P, suffers from back pain and he is determined to find the cause of the pain. To rule of the most lethal causes of back pain, some of the questions Page asks include “Did the pain wake him up at night? Was it worse when he was lying down? Had he recently lost weight?” (Page).
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.
An MRI was performed of the lumbar spine. The examination found no significant extra
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
Counselor met with Pt. for an arranged individual session. Counselor greeted Pt. and encouraged him to discuss his last tx plan, which he did. Pt. informed this writer that his last day in the program will be Wednesday, 3/23/17.
Based on progress report dated 05/23/14, the patient reports of continued dull aching pain and burning sensation into the cervical spine. She received 2 cc of lidocaine with no epinephrine in the bilateral trapezius, cervical rhomboid, and cervical paraspinal muscles on this visit. Based on progress report dated 07/10/15, the patient complains of unchanged, sharp, dull and aching pain in the cervical spine, which radiates to the bilateral upper extremities. Baseline is 6-7/10 pain. Rest and medications help alleviate the pain.
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.
Review of systems is positive for heat/cold intolerance, skin rash, new growth or mole, snoring, ankle swelling, abdominal pain, nausea, muscle pain, muscle weakness and difficulty sleeping. As of this report, an 11-panel urine drug screen was administered on this visit and showed positive for oxycodone. Patient continues with failed back and radicular pain for several years and failing adjuvant and increasing tolerance. A second opinion was advised and proceed with surgery if needed, or a trial of spinal cord stimulator.
All health providers describe neck strain radiating down his shoulder. He had physical therapy three times a week for 6 months but still experienced pain at the end of 2012 to the beginning of 2013 when his physical therapy ended. DHD referred him to Dr. Katzman who discussed the need of surgery to his left shoulder which he didn’t have because no fault cut him off. He also had an MRI of his cervical spine and
Assessment This patient has been taking medication because they suffered a sports injury in 2010. The pills have been prescribed from by their PCP. Therefore, the client tested positive for opiates. The client also states that they have never had any issues with drugs in the past and that they have never had any problems with their professional license or employment.
As per medical report dated 4/26/16, patient’s presenting problem started 14 days ago. Pain is still present in her right knee. Movement worsens symptoms.
Summary of Case Study: Bill is a 34 year old male who has recently been prescribed analgesic and muscle relaxant for his right hip pain. After three weeks of pain he is still experiencing symptoms. However, he is now experiencing stiffness and pain in his left hip as well.
The patient was diagnosed for polyps and multiple diverticula at the age of 68. The Patient suffers of painful osteoarthritis of both knees, shoulder hips. Patient?s mother deceased at the age of 79 from breast cancer and her father deceased at the age of 54 from heart attack. The patient noted with bilateral lower extremities edema, and claimed that she uses 2 pillows as a comfortable position to sleep,
Chiou et al. (1994) found that the most common diagnosis given to nurses was ‘‘muscular strain’’. Lumbar herniation and mechanical back pain develop as a result of poor body mechanics and damage to the body structures. A. Karahan (2004) found that nurses did not use body mechanics correctly while making some movements. In particular, sitting, lifting, extending, and moving the patient to the side of the bed were not done correctlyby the nurses.