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Hscoem Case Studies

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This is a 42-year-old female with a 2/7/2015 date of injury. A specific mechanism of injury has not been described. DIAGNOSIS: low back pain; Lumbago with sciatica right side; Myalgia 12/01/15 follow-up visit identified lower back pain. Patient rates the pain as 7/10. The pain is characterized as burning. It radiates to the neck and upper back. Condition is associated with back pain and difficulty in ambulation. It is aggravated by bending over, lifting, prolonged sitting, prolonged standing and prolonged walking. Application of cold, application of heat, bending forward, medications and rest, relieve the pain. Medication side effects include nausea and vomiting. Patient’s primary care doctor stopped her oral medication due to nausea and vomiting; and her liver function tests were elevated. She does not know names, but the sleep aid and the oral medication for pain during the day were stopped. She tolerates the medications well. Patient shows no evidence of developing medication dependency. Patient does not feel the current medication she is taking adequately addressing her pain needs and would like to try a different medication. The level of sleep for the patient has decreased due to difficulty in failing asleep and due to …show more content…

General Approaches: ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 3 supports an initial course of physical therapy with objective functional deficits and functional goals. Per ODG, physical therapy indications for lumbago, backache unspecified are 9 visits over 8 weeks. The patient has tried other conservative treatments and continues with low back pain and some radicular symptoms. The requesting provider indicated that this is a mechanical axial low back pain and the patient is not a surgical candidate at this time. The provider requested 8 sessions of PT, which are supported by the guidelines. Physical therapy of the lumbar spine could help to provide additional pain relief. Recommend

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The patient has completed physical therapy, time, rest, medications, chiropractic care, and acupuncture with no alleviation of the pain. Significant pathology on the MRI is noted with degenerative disk disease, neural foraminal stenosis and a nerve root impingement in the cervical spine. Treatment plan includes epidural at the bilateral C5-C6 level, continuation with home exercise program and medications and follow up in 2 weeks.

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Lumbar Spine: A Case Summary

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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.

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510 Words | 3 Pages

The claimant has a past medical history significant for an acute depression, asthma, bilateral high-frequency hearing loss, diabetes mellitus type 2, and hypertension. The claimant had an emergency room visit on 05/22/2017 due to left leg cramping. It was noted that she had multiple symptoms including a headache, generalized weakness, arm tightness, unproductive cough, frequent bowel movement, and nausea. Laboratory results showed elevated glucose at 200 and low potassium level at 3.3.

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883 Words | 4 Pages

The patient is taking Norco, Morphine and Xanax. He reported 90 % relief with opioids and ability to do his ADL. There were no signs of abuse or diversion. He is on the lowest dose and denies any side effects. He has failed more conservative treatments, including NSAIDs.

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533 Words | 3 Pages

10/28/15 progress report described that the patient has pain with positive bilateral lumbar facet loading. The patient also complained of unprovoked occasional back spasms. There was little or no improvement in sleep and pain from Trazodone and Tramadol, so the patient had been prescribed Valium 5 mg, Mortin 600 mg, and Cyclobenzaprine. 10/28/15 progress report noted that the Valium was prescribed for insomnia. However, 11/26/15 note states an appeal to the denial of Valium and noted that it was being prescribed to address the muscle spams.

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571 Words | 3 Pages

An orthopedic evaluation report from Anthony Esposito, DO (Physical Medicine & Rehabilitation), dated 06/08/2017, indicated that the claimant reported neck and low back pain rated as 8/10. He stated that pain was aggravated by bending, climbing stairs, reaching, lying down, coughing, and looking up. Continued chiropractic therapy and MRIs of the

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316 Words | 2 Pages

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1379 Words | 6 Pages

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1550 Words | 7 Pages

Low back pain is one of the most common reasons people go to the doctor and in which many people will face at least once in their life time. Low back pain can be experienced by many people at any age, but mostly in those of the aging population. There are many reasons people experience low back pain, but most begin to feel better after several weeks and only rarely do they experience chronic back pain problems. One such chronic low back pain condition that effects the younger population is lumbar spondylolysis. Lumbar spondylolysis is a chronic condition found mostly in young athletes who participate in sports that make the athlete have to repeatedly bend the spine backwards.

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811 Words | 4 Pages

He said he was feeling a sharp pain in his right lower back. He also, explained that he had the pain in his left lower back at first but then the pain traveled to his right side. He did not take any Ibuprofen for the pain at all, and he only felt the pain when trying to fully bend over, for example; to pick something from the floor, or touch his toes.

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652 Words | 3 Pages

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1071 Words | 5 Pages

Physical therapy is the treatment of disease, injury, or distortion by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery. The goals are to help joints move better and to restore or increase your flexibility, strength, endurance, coordination, and balance. This essay will discuss the extent of agreement that physical therapy is vital to be used as non-surgical treatments by people experiencing back and neck pain from time to time. To begin with, taking physical therapy sessions can regain original capabilities. People whom suffered from severe pain every day, tend to lose some of their abilities in handling their daily activities.

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