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
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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
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.
2. EMG/NCV studies consistent with peripheral motor and sensory neuropathies, from October 2008 12/15/15 Progress Report described that the patient has ongoing low back pain. He was last seen on 10/28/15. The patient stated that his current medication regimen has been helpful. He rated the pain 9/10-scale level, which is brought down to 6/10-scale level with the medications.
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
There is decreased sensation of the left anterior thigh. He has forward leaning stiff gait with ability for heel and toe rise.
Range 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.
CURES report was reviewed. Last urine drug screen on 12/04/14 was appropriate. On examination, there is tenderness upon palpation over right medial knee joint line. Mild atrophy of right medial quadriceps muscle is noted.
Based on medical report dated 06/12/15, the patient reports that his left wrist is hurting significantly. He presents with pain and dysfunction of the left wrist. The patient continues to experience substantial discomfort, is frustrated by lack of progress.
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
As per office notes dated 3/30/16, the patient has gradually improved but is still not back to baseline pain. Prolonged standing exacerbates pain. Pain has been more localized recently, with less left lower extremity shooting pain, but has numb sensation in the left leg. Maximum pain is 8 over last month. With oxycodone has a >50% reduction in pain.
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.
Patient is not able to jump. Patient in general with moderate hypermobility of her general joints and slightly decreased her general muscle tone control.
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.
Examination of the cervical spine reveals spasm, pain and decreased range of motion. There is facet tenderness. Examination of the shoulders reveals a positive impingement sign bilaterally. There is painful and limited range of motion bilaterally. Examination of the lumbar spine reveals spasm.
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.