Patient Profile

536 Words3 Pages

DOI: 05/21/2015. Patient is a 52-year-old male control operator who sustained an injury to his low back after lifting 42-pound rolls. Patient is diagnosed with lumbar isthmic spondylolisthesis, lumbar degenerative disc disease, lumbar foraminal stenosis, and lumbar radiculopathy. MRI of the lumbar spine dated 09/01/15 showed L5 to S1 pars defects with mild spondylolisthesis. There is a 4.5mm generalized disc bulging and redundancy of the disc annulus with impingement of existing L5 nerve roots at neural foraminal level, right greater than left. 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. Per the medical report dated 11/10/16, the …show more content…

Patient has had progressive pain, numbness, and weakness in both lower extremities. He has had an epidural, physical therapy, and medications. It was reiterated that the patient has lost over 30 pounds. He has clear-cut instability as documented by the pars fracture and the spondylolisthesis, which is mobile on flexion/extension films. Per the appeal letter dated 12/09/16 by Dr. Deckey, the IW has an isthmic spondylolisthesis with foraminal stenosis and radiculopathy. MD argues that this patient does not warrant a psychosocial evaluation. He is a 52-year-old gentleman. He has lost weight, and he has gone through conservative treatment. A psychosocial evaluation is really an evaluation for patients who have degenerative lumbar disk disease and require surgery for degenerative disk disease. Obviously, there is a significant amount of psychological overlay in these patients. Patient has dynamic instability. He has radiculopathy. He has failed conservative treatment. He has attempted to lose weight and warrants a straightforward surgical

More about Patient Profile

Open Document