Per procedure reports, the patient is status post therapeutic bilateral sacroiliac intra-articular injection on 02/18/16, diagnostic bilateral sacroiliac intra-articular injection on 02/05/16, confirmatory bilateral L3-5 medial branch nerve block on 01/25/16, diagnostic bilateral L3-5 medial branch nerve block on 01/11/16, bilateral L5-S1 transforaminal epidural injection on 04/06/15, bilateral L5 dorsal ramus
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.
Pain is located in the low back and left leg, rated as 4/10. There is associated numbness to the left thigh and foot, and pins and needles sensation to the left foot. He continues with Percocet with 80% help with use. CURES was very consistent and appropriate.
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.
This article presents a case report about a 31 year old male patient, a teacher at a university, who started experiencing mid back pain after weightlifting one day.3 About 3 hours after weightlifting, the patient began to feel sharp back pain, at levels T4-T8. His pain began to worsen that night causing muscle spasms of his paraspinal muscles, with intermittent radiating pain to his lateral thorax and chest.3 This patient had been diagnosed with thoracic facet injuries in the past, and just assumed it was that.3 However, after the pain did not subside the patient went to his physician who claimed the patient was just having muscle spasms and needed myofascial release.3 However, a radiograph was also done that revealed end plate degenerative changes at T7-T8.3 The patients clinical evaluation revealed muscle spasms of the paraspinal muscles between T3-T12, tenderness to palpate between T6-T8, full shoulder ROM, 5/5 shoulder muscle strength, and normal distal pulses and sensations.3 The patient was diagnosed with thoracic pain and muscle spasms and was give muscle relaxants and exercises for myofascial release.3 Three days after the physician visit, the patient decided to do some walking, to work on his cardio, and experienced mild shortness of
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: 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.
Her PCP order radiographs and an MRI both which appeared unremarkable.2 Due to the negative radiographs, her PCP referred her to an orthopedic who linked her back pain to lifting boxes at work, prescribed analgesics, and referred the patient to physical
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,
Low back pain is neither a disease nor a diagnostic entity of any sort. The term refers to pain of variable duration in an area of the anatomy afflicted so often that it is has become a paradigm of responses to external and internal stimuli (Ehrlich GE 2003). Research study on low back pain has shown that it is a common problem in general population. As seen in Western industrialized countries, back pain is one of the major health problems (R Ayiesah and D Ismail 2007).