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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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Based on progress report dated 05/23/14, the patient reports of continued dull aching pain and burning sensation into the cervical spine. She received 2 cc of lidocaine with no epinephrine in the bilateral trapezius, cervical rhomboid, and cervical paraspinal muscles on this visit. Based on progress report dated 07/10/15, the patient complains of unchanged, sharp, dull and aching pain in the cervical spine, which radiates to the bilateral upper extremities. Baseline is 6-7/10 pain. Rest and medications help alleviate the pain.

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410 Words | 2 Pages

DOI: 12/18/2014. The patient is a 56-year old male route sales representative who sustained a work-related injury to his lower back due to slip/fall on black ice while walking from his truck. As per OMNI entry, he was initially diagnosed with lumbosacral sprain. MRI of the Lumbar Spine without Contrast dated 01/23/2015 showed lumbar spondylosis at L1-2 though L5-S1 discs. At L4-5, there is a 4-mm posterior osteophyte-disc complex more prominent laterally and on the left side.

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614 Words | 3 Pages

Per AME report by Dr. Sommer dated 05/28/14, the patient is P & S since 06/13/13. Based on the neurosurgical lumbar spine consultation report dated 12/08/15, the patient states his pain is 5-9/10. The pain is 80% back and 20% in the

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510 Words | 3 Pages

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Left Knee Case Summary

883 Words | 4 Pages

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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

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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

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