Posterior Disc Protrusion Case Studies
DOI: 2/6/2003. The patient is a 46-year old female aide who sustained a work-related injury to her low back while she was transferring a high school student from wheel chair to table.
MRI of the lumbar spine dated 2/19/16 revealed T12-L1, there is no focal posterolateral right disc protrusion; L1-2, no posterior disc protrusion/osteophyte complex; L2-3 , no posterior disc protrusion/osteophyte complex; L3-4, there is lateral left disc protrusion/osteophyte complex; L4-5, there is an approximately 3 mm posterior disc protrusion/osteophyte complex; and L5-S1, there is mild posterior disc/osteophyte complex.
As per office notes dated 3/30/16, the patient has gradually improved but is still not back to baseline pain. Prolonged standing exacerbates pain. Pain has been more localized recently, with less left lower extremity shooting pain, but has numb sensation in the left leg. Maximum pain is 8 over last month. With oxycodone has a >50% reduction in pain. There was no change in the medication list.
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She has had persistent pain since the industrial accident. The attempts to control her symptoms with spinal cord stimulation trial were unsuccessful, which led to infection and removal of abscess. Her left buttock and leg is worse than her back down to her posterior thigh and into the shin. Pain is 3 to 9 in the leg while 1 to 5 in the back. Pain is worse with laying on the left side, walking, or climbing the stairs. It is noted to be better with heat or laying on the right side. The patient is also limping due to pain with weakness and numbness on the left side. She has been treated with Neurontin in the
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
Jimmie Bowman Case Study
362 Words | 2 PagesHe has no Romberg 's sign. IMPRESSION: History of chronic inflammatory demyelinating polyradiculoneuritis. The strength and sensation of his extremities continues to improve after this, with no recurrence of symptoms from this with weaning off of Imuran. PLAN: Continue off of Imuran. Continue observation from a neurological standpoint.
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
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.
Norma Blok Case
596 Words | 3 PagesHer son updated me on medication changes. Her diuretic has been stopped. She does continue to have some leg edema, although it is much better than it used to be. She is wearing compression stockings and trying to elevate it as much as possible. She does avoid salt.
L4-5 Nursing Case Studies
357 Words | 2 PagesAs per office notes dated 7/19/16, the patient complains of chronic low back pain at the localized curvature. There is radiating pain, which is increased since the fall. There is limited range of motion. Pain is exacerbated with walking, standing, and sitting. The patient had post lumbar surgery on August 2015.
Iw Case Report
635 Words | 3 PagesDOI: 5/22/2000. Patient is a 52-year-old female stitcher operator who sustained injury while she was pushing load onto a stitcher when she strained her right shoulder, wrist elbow, and neck. She underwent exploration of cervical fusion at C5-T7 with anterior cervical discectomy with fusion at C3-C5 on 12/13/11 and implantation of new implantable pulse generator (IPG) and spinal cord stimulator unit on 09/17/14. Based on the latest medical report dated 01/29/16, the IW presents for follow up of neck and shoulder pain.
Lumbar Spine: A Case Summary
410 Words | 2 PagesHe 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.
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.”
To Kill A Mockingbird Case Summary
897 Words | 4 PagesWe reviewed differential diagnosis and at this point, because her pain has been persistent now for the last couple of weeks, it is mainly in the left and right upper quadrant, I have recommended that we move forward with an abdominal ultrasound and I will review those results when available. She will also be doing some laboratory studies. She knows that if her symptoms worsen acutely, she will seek care particularly if has vomiting, fevers or worsening abdominal pain. We also talked about possibly having her follow up with Dr. Maher, as well, but we will start the evaluation here. I am going to have her also do a trial of a proton pump inhibitor either Nexium or Prilosec over-the-counter to use for about a week to see if that helps her symptoms, also.
Patient Profile
536 Words | 3 PagesThere 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
Law 421 Week 1 Memo Sample
1383 Words | 6 PagesHis 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.
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