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Acute Injury Case Study

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SUBJECTIVE
Christina sent to physical therapy after acute injury two weeks ago. Reportedly slipped on a wet surface went airborne and landed violently on her buttock. I do not believe this was documented but this was what described to me. She notes prior to that she had no real history of any real back issues and was working in the maintenance job. Oddly, she was in the hospital back in early fall and they did a lumbar MRI which is fairly negative. I do not have the results in the chart at this point. Apparently, it was done because she said she had some leg tingling. I am not sure what to make of that. Regardless, she does not report a lot of history and had a high level of function. Stating she would like to work and be active. She states since his acute fall she has been fairly miserable. She notes intense right buttock and right leg numbness and pain. Pain can fluctuate from a 9/10 to a 0 depending on activity and position. Notes increased pain with Valsalva, coughing, or sneezing, but particularly Valsalva maneuvers. Most relief of pain is supine with the knees
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I extended some of the restrictions including no work as I want patient primary laying horizontal. She can sit for three hours a day in her classroom but other than that, I am going to have her use a Rollator for walking in the unit short distances, wheelchair long distances. With the prednisone she may get better significantly faster so this may change over the next two weeks. I also fitted her with a lumbar support which allowed for standing and walking to be far greater tolerated. She was able to stand and walk with the Rollator with the brace and had a difficult time without it. She can use this brace as need be. Outlined these precautions to the patient and will recheck patient in about two weeks, which is the next time I am
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