Lumbar Pain Case Study
DOI: 06/10/2004. Patient is a female store manager who sustained a work related injury while she was stocking and cashing at a thrift store over a period of time.
Based on progress report dated 08/24/15, the patient was seen for re-assessment of chronic mechanical and myofascial pain in the lumbar region. She has undergone two lumbar surgeries, as well as a left abdominal hernia repair and a revision of the ventral hernia repair.
She reports of increasing lumbar pain, described as aching, burning and stabbing that radiates into the bilateral lower extremities with paresthesias and numbness. Her pain level is an 8/10. The pain is more prominent in the left upper extremity.
She did undergo the bilateral L4-5, L5-S1 facet block which she reports was 75% beneficial in decreasing the deep stiffness aching sensation.
…show more content…
MRI of the lumbar spine done in 06/27/13 showed L1-2, L2-3, L3-4 and L4-5 posterior facet arthrosis. At L4-5, there is a minor residual disc bulge post surgical changes. At L5-S1, posterior facet arthrosis is noted. A right posterior lateral disc hemiation protrusion which abuts the right ventral lateral thecal sac at the S1 nerve root is demonstrated.
On examination, she walks with an antalgic slow gait, which is walker dependent. There are tenderness and trigger points along the bilateral L3, L4, and L5 and bilateral buttock. Straight leg raise is positive bilaterally. Motor strength of the lower extremities is 4/5 to the left and 4+/5 to the
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 PagesPain radiates from the lower back and aggravated by bending, getting in and out of the car, lifting, reciprocating stairs, sitting, standing, turning, twisting and walking which is mildly alleviated by over-the-counter drugs and
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
Percocet Case Summary
284 Words | 2 PagesThere is decreased sensation of the left anterior thigh. He has forward leaning stiff gait with ability for heel and toe rise.
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.
Work Related Injury Case Summary
340 Words | 2 PagesCURES 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.
Post-Concussive Syndrome: Case Study
732 Words | 3 PagesGait Markedly antalgic. Equivocal Romberg. DTRs 2+ in the upper extremities and knees, trace at the ankles. Labs/Studies CAT scan and C-spine are as noted
Hypnotherapy Case Studies
222 Words | 1 PagesReview # 259374 Lucila Fernandez DOI: 03/28/2016. This is a 52-year-old female housekeeper who sustained an injury when she lost footing and twisted her right knee before completely falling 2 flights of stairs. The patient was subsequently diagnosed with meniscal tear. MRI of right knee without gadolinium dated 4/23/16 revealed there is a high-grade sprain of the ACL; there is a low-grade sprain of the MCL; there is a vertical oblique tear through the body of the medial meniscus with underlying chondromalacic change and subchondral edema; and mild to moderate chondromalacia of the patella.
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
Reconsideration-Disability Hearing Unit Case
323 Words | 2 PagesMedical Records Information: Swollen lower extremities, tender to palpation lower back, right knee and left shoulder. Limited range of motion neck and lower back. Unable to squat, unable to walk on heels and toes. Asthma, sleep apnea, obesity (11/21/2014 weighed 304.4 pounds), diagnosed with rheumatoid arthritis. Was receiving mental health treatment for major depression and chronic pain in the lower back and legs, pain was “becoming intolerable.”
Fusion Case Studies
614 Words | 3 PagesDuring 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
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
Nursing Case Study Essay
1118 Words | 5 PagesNajla Morshidi NURS 301 Case Study Health History and Analysis of Finding A 75 year old female patient alert and oriented X 3, weigh 115 Lbs, her height 5?8?? , has a hearing aid and wear glasses for reading. The presented Patient has a history of hypertension diagnosed with CHF on 2013, positive for Hepatitis B due to contaminated blood transfusion. Had a cervical dysplasia on 1994 resolved by a total abdominal hysterectomy and bilateral oophorectomy the following year.
Patient Reliability
1560 Words | 7 PagesShe noticed slight swelling of her right lower extremity about one month ago after prolonged standing. Swelling is intermittent with slight discomfort which is relived by elevating her legs using 2 pillows. Past Medical
More about Lumbar Pain Case Study
Orleda Lee Harris Case Summary
302 Words | 2 PagesNursing Case Memo
647 Words | 3 PagesLow Back Pain Case Studies
934 Words | 4 PagesRoom 3b Case Study
859 Words | 4 PagesPercocet Case Summary
284 Words | 2 PagesIw Case Studies
312 Words | 2 PagesWork Related Injury Case Summary
340 Words | 2 PagesPost-Concussive Syndrome: Case Study
732 Words | 3 PagesHypnotherapy Case Studies
222 Words | 1 PagesPneumothorax Presentation
891 Words | 4 PagesReconsideration-Disability Hearing Unit Case
323 Words | 2 PagesFusion Case Studies
614 Words | 3 PagesInvestigative Tort
527 Words | 3 PagesNursing Case Study Essay
1118 Words | 5 PagesPatient Reliability
1560 Words | 7 Pages