Client has pain when extending the neck towards the sternum, lateral extension of the right side, and reduced range of motion in rotation of the neck towards the left side of the body. Patient explains that prior to her injury she could touch her chin to her sternum area, easily rotate her head from right to left and look over her shoulder. She complains of lack of sleep due to pain, headaches, problems with driving and inability to bend neck to read, eat, and engage in office/school work. Client loves to take long drives, put together puzzles, and play video
On examination of the back, there is tenderness upon palpation midline of the lower lumbar and sacral region. Posture shift is to the left.
EXAMINATION: He continues awake and alert. He converses easily and appropriately. He is in no acute distress. Blood pressure 120/78. Pulse 70 and regular. Weight 177 pounds. Height 5 '6". Cranial nerves continue intact, including the extraocular eye movements being intact without nystagmus. Visual fields are full in both eyes. He had no papilledema or atrophy of either optic disc. Pupils react from 4 down to 2 mm, bilaterally brisk and round to light and accommodation. He continues to have good strength with normal bulk and tone throughout his extremities. He had normal sensation to light touch, pinprick, and vibration sensation throughout both upper and
“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
Based on progress report dated 07/10/15, the patient complains of unchanged, sharp, dull and aching pain in the cervical spine, which radiates to the bilateral upper extremities. Baseline is 6-7/10 pain. Rest and medications help alleviate the pain. 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
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.
Both the ambulance and the police arrived at the scene and took him to Kings County Hospital but because of the long wait they went to Beth Israel. His aunt drove him and his girlfriend. At the hospital he complained about his shoulder and wrist on the left side. He doesn’t remember the hospitals instructions regarding follow up care and he never returned to the hospital. His record says he complained about back problems and that he refused immobilization but he did go to DHD Medical and Dr. Katzman. 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
Per the medical report dated 09/29/16, patient complains of back pain, rated as 8/10, radiating to both lower extremities, worse with standing and walking.
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
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
Pt is doing extremely well for the number of visits that she has received. This is because of her hard work at home which has contributed to her fast recovery. Her ulnar/radial deviation lacks because of the muscle tightness which could be loosened
The literature supports the view that the prognosis of individuals with LBP is not as good as previously thought. The typical recovery is slow, and patients may still have pain and disability for one year 54-58. Therefore, individuals with LBP need effective comprehensive treatments to minimize pain, optimize function and participation, and prevent recurrence of a LBP episode. Guidelines for evidence-informed primary care management of LBP recommend that clinicians from different disciplines be part of individuals’ care including physicians, nurses, physical therapists, occupational therapists, psychologists, chiropractors, and pharmacists 59. This interdisciplinary/multidisciplinary approach is needed
Thank you for your overview. Your protocol seems a faster, accelerated protocol for someone with RTC and SLAP repair. Your patient had also SLAP repair 1 year ago right? What was his pain level before and after rehabilitation? And, how many visits (average) did he need to reach phase IV?
Conservative treatment has been tried for more than 3 months but it failed. Pain scale is 10 without medications and 6 if with medications. There is 50% improvement with opioid medications. With medications, the patient is able to ambulate 5 feet as baseline and with medications, he is able to ambulate 100 feet. The location of pain is at the left knee, shoulder, and back pain. He describes it as aching, annoying, constant, intense, sore and tight. Recent hospitalizations notes that the patient had left knee surgery on 4/12/16. Physical examination revealed that he is shifting position in the chair frequently die to pain. He is tender over the upper thoracic spine. Impression notes that his left knee is healing well; he is scheduled to have physical therapy; and back pain is worsening. As per documentation of medical necessity for Norco. The patient notes that the pain is 7 before taking medication and that after taking the medication, the pain is decreased to a tolerable 5/10. He notes that without pain medication, he is unable to sit or stand for prolonged periods of time. Moreover, he is unable to work for any length of time without the medications. The pain also keeps him from being able to
The patient is a 95-year-old gentleman who fell approximately 5 days prior to presentation. He was found at the curbside after he fell trying to throw his carbage away. He was seen by his primary physician on the 4th, had a severe hematoma of the right shoulder, was sent for x-ray studies and referrals made for visiting health services and home health aide services. When the official results arrived it was noted that he had comunated fracture of the clavicle rotator cuff injury and some possible rib fractures on the right side. The patient ambulates with a cane and basically uses his right hand to ambulate so he presented great difficulty and he does live alone so he was referred inpatient for further evaluation. His medical history is