Nursing Case Studies

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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…show more content…
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

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