DOI: 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.
DOI: 12/18/2014. The patient is a 56-year old male route sales representative who sustained a work-related injury to his lower back due to slip/fall on black ice while walking from his truck. As per OMNI entry, he was initially diagnosed with lumbosacral sprain. MRI of the Lumbar Spine without Contrast dated 01/23/2015 showed lumbar spondylosis at L1-2 though L5-S1 discs. At L4-5, there is a 4-mm posterior osteophyte-disc complex more prominent laterally and on the left side.
The patient has completed physical therapy, time, rest, medications, chiropractic care, and acupuncture with no alleviation of the pain. Significant pathology on the MRI is noted with degenerative disk disease, neural foraminal stenosis and a nerve root impingement in the cervical spine. Treatment plan includes epidural at the bilateral C5-C6 level, continuation with home exercise program and medications and follow up in 2 weeks.
DOI: 05/21/2015. Patient is a 52-year-old male control operator who sustained an injury to his low back after lifting 42-pound rolls. Patient is diagnosed with lumbar isthmic spondylolisthesis, lumbar degenerative disc disease, lumbar foraminal stenosis, and lumbar radiculopathy. MRI of the lumbar spine dated 09/01/15 showed L5 to S1 pars defects with mild spondylolisthesis.
The patient is an 84-year-old female who had a history of a fall approximately 2 weeks ago. She was seen in the ED at St. Joseph 's in Wayne at which time she had right hip and pelvic x-rays and also a CT of the of the hip. There was some question as to whether she had developed a fracture or dislocation of a previous hip prosthesis. The patient was in excruciating pain and was having difficulty ambulating. Her medical history is significant for diabetes mellitus, hypertension, Alzheimer 's disease, right hip fracture surgery back in January 2014.
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
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.
As per office notes dated 7/19/16, the patient complains of chronic low back pain at the localized curvature. There is radiating pain, which is increased since the fall. There is limited range of motion. Pain is exacerbated with walking, standing, and sitting. The patient had post lumbar surgery on August 2015.
He is weaning off his medications. CURES report was reviewed. The patient stated that pain is relieved by medications and aggravated by sitting and standing. Current meds included morphine, amlodipine, maxzide, ecotrin, halfprin, testosterone injection, Suboxone, Norco, dyazide and alprazolam. The exam revealed normal gait.
DOI: 12/13/2012. This is a case of a 63-year-old male security officer who sustained a work-related injury to the right knee when he missed a step and fell down the stairs. As per Omni, the patient had a right knee meniscus tear. The patient had right knee replacement on 11/19/14.
DOI: 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.
This is a 42-year-old female with a 2/7/2015 date of injury. A specific mechanism of injury has not been described. DIAGNOSIS: low back pain; Lumbago with sciatica right side; Myalgia 12/01/15 follow-up visit identified lower back pain. Patient rates the pain as 7/10. The pain is characterized as burning.
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
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.