Nursing Case Studies
DOI: 01/05/2004. Patient is a 64-year-old female nurse who sustained a work related injury to her cervical spine, lumbar spine, and bilateral shoulders during the course of performing her normal job duties.She is statius post bilateral L4-5 and L5-S1 facet blocks with fluoroscopy on 10/23/12. MRI of the lumbar spine dated 01/08/16 revealed moderate levoscoliosis; L1-L3 2-3mm posterior disc protrusion; L3-L4 4-5mm pseudo and/or true posterior disc protrusion; L4-L5 3-4mm posterior disc protrusion/extrusion; L5-S1 2-3mm posterior disc protrusion.
Based on the progress report dated 05/19/16, the patient presents for a follow-up orthopedic re-evaluation. She states that she finally got her Voltaren 1 week ago and she noticed that she has been able to walk with less
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Examination of the cervical spine reveals spasm, pain and decreased range of motion. There is facet tenderness. Examination of the shoulders reveals a positive impingement sign bilaterally. There is painful and limited range of motion bilaterally.
Examination of the lumbar spine reveals spasm. Range of motion is painful. There is tenderness to palpation over the facet joints. There is pain with flexion/extension at L3-5 bilaterally. There is pain with prolonged sitting and standing.
Patient was diagnosed with lumbar discogenic disease, anterolisthesis of L3 and L4, lumbar facet arthrosis, chronic low back pain, cervical discogenic disease with facet arthropathy, bilateral shoulder impingement syndrome and status post bilateral shoulder surgeries.
Treatment plan includes a L3-5 facet block x 1 as the patient has pain with flexion and extension, and has 60-70% improvement for 3-4 months with a previous facet block to the lumbar spine. There is a change and worsening in her condition. She was given a prescription for Voltaren 75 mg one tablet twice daily for pain and inflammation #60 and Prilosec one tablet twice daily #60 for gastrointestinal
Orleda Lee Harris Case Summary
302 Words | 2 PagesAn MRI was performed of the lumbar spine. The examination found no significant extra
Cpt Hu Case Study
113 Words | 1 Pages3. Partial thickness articular surface tear of the remaining portion of the supraspinatus tendon and infraspinatus tendon and subscapularis tendinopathy. 4. Severe osteoarthritis of the glenohumeral and acromioclavicular joint.
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 Pages2. EMG/NCV studies consistent with peripheral motor and sensory neuropathies, from October 2008 12/15/15 Progress Report described that the patient has ongoing low back pain. He was last seen on 10/28/15. The patient stated that his current medication regimen has been helpful. He rated the pain 9/10-scale level, which is brought down to 6/10-scale level with the medications.
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 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 PagesActivities 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
Work Related Injury Case Summary
340 Words | 2 PagesStrength is 4/5 with knee extension on the right compared to the left. Patient is able to raise from a seated position with mild difficulty. Gait is antalgic. Current medications include Atenolol, Norco 10-325 mg 1 tablet every 6 hours as needed and Cyclobenzaprine 10 mg 1 tablet 3 times daily. IW was diagnosed with knee pain.
Left Wrist Case Summary
247 Words | 1 PagesBased on medical report dated 06/12/15, the patient reports that his left wrist is hurting significantly. He presents with pain and dysfunction of the left wrist. The patient continues to experience substantial discomfort, is frustrated by lack of progress.
L4-5 Nursing Case Studies
357 Words | 2 PagesTreatment 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
Iw Case Report
635 Words | 3 PagesIW had a left C2-C3 and C4-C5 TFEI on 7/20/15.Pre/post visual analog scale (VAS) score is 5/10 to 2/10 (50% pain relief). IW had a right C2-3 and C4-5 TFEI on 3/09/15. Pre and post visual analog scale (VAS) score is 7/10 to 3/10 (50% pain relief). Relief lasted 2-3 months for each procedure. With radicular symptoms resolved, household chores made easier.
Radiological Evaluation Paper
1158 Words | 5 PagesClinical Orthopaedics and Related Research®, 471(4),
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
Red Flags Case Study
746 Words | 3 PagesIntroduction Patients with spine pain generally present with a clinical picture that could be created by many different conditions and therefore it is vital that clinicians identify these conditions that may delay a patient’s recovery and function or put them at risk for serious medical consequences. These conditions are known as red flags. Red flags are signs and symptoms that are found in the patient’s history and clinical examination that can link to a serious pathology. They may require further diagnostic assessment and possibly immediate treatment by a specialist. Red flags must be ruled in or out prior to treatment, the likelihood of which can be improved by thorough consideration of patient history, characteristics of the present complaint and physical examination and
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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