Algaher A Case Study

Based on the latest medical report dated 04/08/16, the patient presents for follow-up of his lower back pain. He is status post radiofrequency facet on the left that initially helped with left sided lower back to 60%. He stated that PT was stopped by insurance for the past 2 weeks. Since he started PT, he has been having increased spasm across his lower back with pain into the left lower extremity. IW feels that PT

On 9/23/16 I met with Mr. Russell at the Covenant Occupational Medicine. Mr. Russell said his pain level is at a 1 to 2 now. He is able to tolerate sitting, standing and walking more since starting physical therapy. He reports he is doing a home exercise program also. Dr. Eckstein said he would increase his work restrictions. He would like him to have 2 more weeks of physical therapy. He hopes at the next appointment to be released.

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

In addition, CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. As noted above, this is an appeal to the previously denied request on 02/09/16. The appeal letter states that the patient has low back pain. MRI report showed disc bulge at L5-S1 with left neural foramina narrowing. However, 01/06/16 progress report noted that there was no radiculopathy with a negative SLR on exam. The guidelines require documentation of radiculopathy on exam. In addition, there is no documentation of a trial or failure of conservative treatment, including PT, as recommended by the guidelines. Furthermore, there is no documentation of any focal neurological deficits on the exam that would indicate nerve pathology. The motor and sensory exam was normal. Medical necessity has not been established. Recommend

On 1/16/17 I met Mr. Anderson at the office of Dr. Rampersaud. Mr. Anderson drove to the appointment. He uses 2 canes to walk. He reports that he and his wife drove to Florida on 1/4/17 to 1/15/17. He said they walked everyday while he was there. He reports his pain is a 9. The pain is in the left Si and caudal along with the low back. Mr. Anderson is scheduled for several injections today after we meet with Dr. Rampersaud. Mr. Anderson’s current medications were discussed. I remind Dr. Rampersaud that we are on a tapering process with the medications. Mr. Anderson was instructed to decrease the Dilaudid to 3 times per day from 4; the

Based on the medical report dated 04/01/16, the patient complains of pain in the neck with radiation to bilateral upper extremities and pain to the lower back with radiation to the lower extremities with tingling/numbness and weakness. He rates his pain 8-9/10.

Patient was encouraged to continue with heat, followed by his home exercise program and ice. He will continue with his transcutaneous electrical nerve unit (TENS). Patient was given an ice pack to use, to reduce pain. He was given a 60 mg Toradol injection on this visit.

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

The patient has a history of discectomy to the left with temporary improvement of his lumbar pain and lower extremity symptoms. He has reherniation to the left correlating to the L4-L5. He has had transforaminal epidural steroid injections and facet injections with relief of his lumbar pain.

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

It was noted that symptoms were improved from her lumbar epidural steroid injection done on 8/11/15. He was able to get up and down from chair more easily, able to get into and out of the bed and car more easily, able to walk, sit, stand for longer times, and stooping/bending improved. He was able to reduce oxycodone use by 50% following procedure. She feels that now the effects of the procedure are worn off. The patient states she is doing fine as long as she can get her medications filled. Musculoskeletal examination revealed laminectomy scar, tenderness at bilateral lumbar facet column, and positive lumbar pain with extension/ rotation. It was also noted that the patient is positive for pelvic tilt, left hip lower and that right sacroiliac joint and greater trochanter are tender. Lower extremities revealed mild edema at bilateral lower extremities, greater in left leg. There is also tightness noted bilaterally during seated straight leg raise. Attached in this review is the operative report on

The purpose of this paper is to analyze information on a pregnant patient. The information will be compared to the expected normal patterns of a healthy pregnancy. Risk factors will then be looked at for implications and recommendations for ways to improve health of the patient. Finally, teaching and anticipatory guidance for this specific patient will be given.

Treatment Plan Modified: the rod and screws were removed to see if that would reduce Mr. Andersons reported pain levels. Testing was done to determine pain generators have not supported any further surgery. Mr. Anderson has been told he may have to learn to live with the pain. Attempt to increase activity level with physical therapy showed no progress and was discontinued as of 5/1/17. SPC implanted 6/19/17 to assist with pain control.

On 4/19/18 I met Mr. McDonald at the office of Dr. Rampersaud. Mr. McDonald reports that he is about 50% better with the Lyrica; he rates his pain at a 7. He is tender to touch over the bilateral Si joints and has pain to the L1 spine area. He reports he has been taking one Norco at night to help with his sleep. We again discussed the Kyphoplasty. Mr. McDonald told Dr. Rampersaud that he is being sent to see Dr. Palavali for a 2nd opinion regarding the Kyphoplasty. He said he has had surgery in the past with Dr. Palavali and trust him. In the meantime Dr. Rampersaud told him that is he wants to proceed he could always put this through his personal health insurance and move forward on the Kyphoplasty. Mr. McDonald said he really doesn't do anything at home; his wife won't let him pick up a bag or anything. He feels very weak. Dr. Rampersaud said he has let himself get de-conditioned. I remind him of the physical therapy and the work hardening he had before. Dr. Rampersaud would like him to start a reconditioning program with

There have been no major changes in Mr. Dawkins’s pain level. Rebecca Berner RN CCM attended the scheduled pain management appointment on November 1, 2017. Mrs. Berner arrived at the pain clinic this morning at 10:00 am. Mr. Dawkins got there at 10:40 am. He was ambulatory and said his pain was about the same-primarily in his left shoulder. He could raise his left arm about 110 degrees and said it was better than before, but said he could not reach around to wash his back. He also indicated he completed all the pre-requisite testing to move forward with the surgery and wanted to know what the delay was. After an hour and a half, we were placed in an exam room and the medical assistant asked him why he had filled a script for Tylenol #4's.