DOI: 01/31/2006. Patient is a 39-year-old male plumber who sustained a work-related injury to his back and elbow when he slipped and fell while going down the stairs. Per OMNI, he is status post lumbar fusion at L5-S1 on 7/19/10. The patient was declared permanent and stationary as of 8/15/11 with future medical care including physician visits, medications, possible surgery, bone growth stimulator, lumbar brace, and vocational retraining. On 12/18/12, he underwent removal of hardware and inspection of fusion.
Per AME report by Dr. Sommer dated 05/28/14, the patient is P & S since 06/13/13.
Based on the neurosurgical lumbar spine consultation report dated 12/08/15, the patient states his pain is 5-9/10. The pain is 80% back and 20% in the …show more content…
The patient used a four poster walker after the spinal surgeries in 2010 and then graduated to a cane after hardware removal in late 2012. He is now taking Norco 5 mg 4 times daily. He has not had any physical therapy in the last two years and does not recall being given home exercise program from physical therapy. He is not doing home exercises. He has not had any epidural steroid injections and chiropractic treatment for the last two years. He does have a TENS unit, which he uses intermittently. As of this report, the first surgery helped him 10%, and the second surgery had no benefit. On examination of the lumbar spine, standing range of motion is 20 degrees. Straight leg raising is 80 degrees on the right, and 90 degrees to the left. There is diminished right heel/toe walking/raising. Patient is only able to do heel-to-toe raising about 0.25 inch off the ground. His gait is broad based. Tandem is not possible. He uses a cane. There is an obvious limp. During examination, he leans to the left to unload the right side and fidgets and changes positions every 5-10 minutes. Hip exam shows positive Patrick’s test and trochanteric percussion on the right. Knee reflexes are 1-2. Ankle reflexes are absent. Motor shows 4/5 weakness, 60-80% of normal, in the right
Click here to unlock this and over one million essaysShow More
DOI: 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.
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
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.
Activities at home and work worsen the pain. Numbness, tingling, and burning sensation are reported with increased pain throughout the week. The patient is requesting medication refills and reports limitations with gripping, grasping, pushing, pulling, and lifting 10 pounds. Activities of daily living are limited due to pain, as
Strength is 4/5 with knee extension on the right compared to the left. Patient is able to raise from a seated position with mild difficulty. Gait is antalgic. Current medications include Atenolol, Norco 10-325 mg 1 tablet every 6 hours as needed and Cyclobenzaprine 10 mg 1 tablet 3 times daily. IW was diagnosed with knee pain.
As occupational therapy assistants one plays an intricate part in treating and caring for the client. In order to ensure that the client is treated properly and that they are progressing towards meeting their final outcome a treatment plan must be created. It is important that throughout treatment the occupational therapist (OT) and occupational therapy assistant (OTA) use independent professional judgement in order to ensure clients best interest are being met. The treatment plan consist of a three step intervention process: intervention plan, intervention implementation, and intervention review.
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
She has had persistent pain since the industrial accident. The attempts to control her symptoms with spinal cord stimulation trial were unsuccessful, which led to infection and removal of abscess. Her left buttock and leg is worse than her back down to her posterior thigh and into the shin. Pain is 3 to 9 in the leg while 1 to 5 in the back. Pain is worse with laying on the left side, walking, or climbing the stairs.
Knee and ankle jerks are 1+, bilaterally. There is weakness of the quadriceps, hamstrings as well as the flexors and extensors of the hips. Assessments include cervical sprain, lumbar sprain, constipation, left carpal tunnel syndrome, lumbar degenerative disc disease, and retrolisthesis at L5-S1. Patient was given prescription for Norco 5/325 mg one tablet twice daily for severe pain #60, Motrin 800 mg 1 tablet twice daily as needed for inflammation and pain #60 and Flexeril 7.5 mg 1 tablet at bedtime for muscle relaxation #30. Requested from the provider’s office copies of recent urine d rug screen and Controlled Substance Utilization Review and Evaluation System (CURES) reports; however, no reports were received prior to the submission of this request to PA.
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.
The male appeared to be in his 70’s. Akinesia, bradykinesia, and postural abnormalities was observed during the session. For example, his delayed response to questions where his caregiver had to tap him before he answered indicating bradykinesia. Akinesia was expected from his reduced limb gestures during speech. A wheelchair appeared to be his primary mode of transportation suggesting he may have difficulty maintaining balance while walking.