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. There is moderate to severe narrowing of right and severe narrowing of the left L4-5 neural foramina. At L5-S1, there is a 4-mm posterior osteophyte-disc complex with moderate narrowing of the neural foramina bilaterally.
Per operative report dated 05/20/2015, the patient …show more content…
He has some numbness and tingling into the posterior aspect of the left thigh and states that after the facet joint injections, he has had about two to three weeks of complete pain relief. He has noticed increased pain in the last couple of weeks with symptoms similar prior to the injection. He has been using ibuprofen and Robaxin with good benefit and states that the pain is usually worse with activity, standing for long periods of time. The patient had previously completed six physical therapy sessions, 12 chiropractic sessions, and 12 acupuncture sessions, but continues to have symptoms down his left …show more content…
He previously had facet joint injections but only with short term good benefit. He continues to take ibuprofen and Robaxin as needed.
On examination of the lumbar spine there is pain on palpation over the lumbar paraspinals. Range of motion was full. Pain is worse on extension and rotation. Sensation is intact to light touch and pinprick in all dermatomes in the bilateral lower extremities.
Diagnoses are lumbago and facetogenic
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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.
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.
Jimmie Bowman was seen in followup for CIDP, causing previous weakness and numbness of his distal lower extremities. He states that the strength of his distal lower extremities [____] continues improved and is staying normal. He has occasional mild feeling of numbness of his feet, but states this is staying down to what he can tolerate. He is not having pain of his feet. He is no longer on Imuran.
He is currently complaining of recurrence of the pain. In regards to his left knee, he states that pain is much better compared to prior to surgery. His main complaint is weakness and difficulties going up and down the stairs. He had his recent physical therapy approved and he has done 2 sessions and he has additional 10 sessions left. Physical examination revealed healed surgical scar left knee.
As per progress report dated 4/27/16, the patient complains of cervical spine pain with left shoulder/hand radiculopathy. Upon examination, there is tenderness to palpation in the left trapezoid. There is positive Spurling’s test noted. Left hand/shoulder examination reveals positive Phalen’s and Tinel’s syndrome. Cervical and left shoulder/hand motor muscle strength is 4/5.
Initial diagnosis was birth defect in lower spine, post surgery diagnosis is damaged nerves caused by surgery b. Symptoms started 2 years ago, surgery happened 1 ½ years ago, move to California 1 year ago. c. Cause was determined to be birth defect then surgery mishap when screw penetrated nerves during surgery. d. Susie’s consequence of the disease is her loss of mobility and independence, intolerable pain and suffering. e. Susie believed her behavior had nothing to do with her medical condition and wouldn’t influence her Treatment and Receiving Medical
Review # 258421 william Rose DOI: 4/24/1991. DOI: 4/24/1991. The patient is a 72-year old male truck driver who sustained injury to his back as a result of driving the truck over a rut on the road. The patient was subsequently diagnosed with lumbar spondylosis, lumbar degenerative disc disease, other specified postprocedural states, and lumbago.
The symptoms are reduced by taking medications, applying ice /heat compresses, transcutaneous electrical nerve stimulation (TENS) unit and massaging. Physical examination is essentially unchanged. Spinal restrictions/subluxations are noted at T1-12 and L1-L5. Pain/Tenderness is noted over the upper to mid/mid to lower cervical, cervico-thoracic, upper/mid/lower thoracic, thoraco-lumbar, upper/lower lumbar and lumbo-sacral and left shoulder.
Palpation of the lumbar spine revealed hypertonic spasms along the lumbar paraspinal muscles bilaterally. Sensation is decreased to sharp at the thigh, foot at L4, L5, and S1 on the right. Lumbar spine range of motion is restricted due pain and stiffness on flexion, extension and left lateral bending. Straight leg raise is positive on the right. Range of motion of the left wrist is restricted on flexion and extension due to pain.
He had a pituitary tumor removed, an operation on his knee and metal pins placed in his hips. And his jaw was split into fine pieces in order to be expanded because of the acromegaly. Doctors Notes • Swelling of right knee. • Ulcerated sores on lower left leg. • Abnormal hormone levels.
Per pulmonary function tests, his condition was stable. Degenerative disc disease lower back and neck, lower back pain. Degenerative joint disease right knee. Right and left knee scope in 2008, right knee scope in 07/2010, decreased range of motion bilateral knees. Independent with activities of daily living.
This pain stopped him from daily living activities such as driving, and also walking. A gait analysis was performed to find that he had an early heel rise on the left, and a short step length on the right. He had to have assistants from the rails to descend and ascend the stairs. Radiographs were performed and showed presence of retrocalcaneal exostoses.