L4-5 Nursing Case Studies
DOI: 07/17/2013. This is a 25-year-old female cashier who incurred injury to her low back when she missed a step and fell off a ladder while stocking sleeping bags. MRI of the lumbar spine dated 10/03/2013 revealed broad based central disc protrusion at L4-L5; moderate discogenic edema along endplates at L4-5; and broad bulge with a central annual tear at L5-S1. CT scan of the lumbar spine dated 01/08/2014 revealed that at L3, bilateral pars interarticularis defects are seen with sclerotic margins. The vertebrae at L3-4 are normal in present on the prior MRI. The vertebrae at L3-4 are normal in alignment. At L4-3, there is 2 mm of anterolisthesis. Bilateral L4 pars interarticularis defects are seen with sclerotic margins. Office notes dated 06/28/2016 …show more content…
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. She states that the pain is progressively getting worse. Objective findings revealed pain in the lumbosacral region, more in the sacroiliac joint. Positive findings on fortin finger flexion test. There is limited lumbar flexion. The patient is subsequently diagnosed with lumbar sacral spondylosis; sacroiliac joint arthritis; and low back pain. Treatment plan includes diagnostic bilateral sacroiliac joint injection under ultrasound guidance. Then if the patient received good relief, then she is to proceed with sacroiliac joint radiofrequency ablation. A course of physical therapy would be appropriate since she has not had any physical therapy for increasing range of motion since her surgery 8/4/2015. Plan also includes weaning off opioid
Orleda Lee Harris Case Summary
302 Words | 2 PagesAn MRI was performed of the lumbar spine. The examination found no significant extra
Nursing Case Memo
647 Words | 3 PagesDOI: 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.
Low Back Pain Case Studies
934 Words | 4 PagesThis is a 47-year-old male with a 2/1/2007 date of injury, who injured his low back from lifting a large bucket of cut grass. DIAGNOSIS: 1. Left SI radicular symptoms. Lumbar discogenic pain with high-intensity zone at L5-S1 per MRI April 2007. X-ray showed 4-mm retrolisthesis at L5-S 1.
Room 3b Case Study
859 Words | 4 PagesQEP 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
Sacroiliac Joint Dysfunction Essay
731 Words | 3 PagesIn healthy individuals, anterior rotation of the innominate occurs during extension of the freely swinging leg. When the innominate anteriorly rotates, it glides inferiorly down the short arm and posteriorly along the long arm of the SIJ. In non-weights bearing an arthrokinematic glide between the innominate and the sacrum occurs during posterior rotation of the innominate and is physiological (i.e., follows the articular surfaces). In weight bearing, the close-packing of the SIJ precludes this physiological glide. Sacral nutation produces the same relative arthrokinematic glide as posterior rotation of the innominate (inferoposterior motion of the sacrum is the same as anterosuperior motion of the innominate); sacral counternutation produces the same arthrokinematic glide as anterior rotation of the innominate (anterosuperior motion of the sacrum is the same as inferoposterior motion of the
Percocet Case Summary
284 Words | 2 PagesPain 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.
Iw Case Studies
312 Words | 2 PagesRange 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.
Left Wrist Case Summary
247 Words | 1 PagesHe was diagnosed with wrist pain. Plan is for a left wrist scaphoid excision, 4 corner fusion. This will require use of the Stryker EasyClip staples. He is currently taking Ibuprofen 800 mg 1 tablet 3 times a day.
Pneumothorax Presentation
891 Words | 4 PagesThis 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
Fusion Case Studies
614 Words | 3 PagesHe 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.
Investigative Tort
527 Words | 3 PagesAll 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
Patient Profile
536 Words | 3 PagesPatient has had progressive pain, numbness, and weakness in both lower extremities. He has had an epidural, physical therapy, and medications. It was reiterated that the patient has lost over 30 pounds. He has clear-cut instability as documented by the pars fracture and the spondylolisthesis, which is mobile on flexion/extension films.
Medical Clinic Observation
811 Words | 4 PagesHe said he was feeling a sharp pain in his right lower back. He also, explained that he had the pain in his left lower back at first but then the pain traveled to his right side. He did not take any Ibuprofen for the pain at all, and he only felt the pain when trying to fully bend over, for example; to pick something from the floor, or touch his toes.
Law 421 Week 1 Memo Sample
1383 Words | 6 PagesHis 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.
Nursing Case Study Essay
1118 Words | 5 PagesThe 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,
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