Case Study: Sacroiliac Trauma

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.

12/31/15 Progress Report described that the patient has cervical spine, right shoulder, and right wrist pain. She rates her cervical spine at 8/10-scale level and frequent; right shoulder pain at 8/10-scale level; and bilateral wrist pain at 6/10-scale level. The pain is frequent and improved since last visit. Rest and medications make the pain better. Weather

DOI: 10/20/2014. Patient is a 46-year-old male delivery driver who sustained injury while he was unloading fittings and flanges to job site. Per OMNI, he was initially diagnosed with lower back strain/sprain.

DOI: 12/19/2015. Patient is a 23-year-old male field technician who sustained injury while removing a ladder from a truck. Per OMNI, he was initially diagnosed with back sprain/strain.

Based on the progress report dated 11/10/16, the patient complains of constant lumbar spine pain, rated as 2/10. Pain is described as sharp, stabbing and throbbing. Pain is aggravated by prolonged sitting, standing and walking, and relieved by rest.

On admission, Ms. Kelly complained of low back pain ranging in intensity from 7 to 8, out of 10, on the pain scale where 0 is no pain and 10 is the worst imaginable pain. She subjectively describes this pain as throbbing, stabbing, burning and radiating along the posterior and anterior aspect of both upper legs, left worse than right. She has sharp, stabbing, burning pain in both her arms, particularly the left arm, and experiences intermittent tingling and numbness sensations in both her hands as well. She has pain in her neck and shoulder that she defines as tension-type pain. Factors that can aggravate the

DOI: 12/14/1995. Patient is a 66 year-old male truck driver who sustained injury to his back while unloading a truck by hand. Per OMNI, patient is diagnosed with failed back syndrome. MRI of the lumbar spine dated 6/9/16 revealed postsurgical changes of the lumbar spine with resection of the posterior elements from L1-L2 to L5-S1 and mild to moderate disc degenerative disease of the lumbar spine at T12-L1, L2-L3 and L3-L4. Per progress report dated 5/03/2016, patient presents for follow up evaluation. He reports that he decided not to proceed with the pain pump trial as he does not want to add more medication to his regiment. He would prefer to start physical therapy for his pain instead of medication. He has been able to control his pain with regimen. He notes at least 40% improvement with

DOI: 09/13/2006. Patient is a 40-year-old male traffic control technician who sustained a work-related injury to his back from lifting arrow board trailer. Per OMNI, he was diagnosed with lumbar herniate d nucleus pulposus. Patient was deemed maximum medical improvement (MMI) on 09/22/08 at maximum medical improvement (MMI) with 18% permanent disability. Future medical care include orthopedic visits, PT, gym membership, MRI, Epidural Steroid Injection (ESI) and back surgery.

The latest progress report noted that the patient has neck and low back pain rated 7/10. The Physical exam revealed restricted ROM in the lumbar spine. TTP and

DOI: 9/15/2008. Patient is a 63-year-old female home attendant who sustained injury while she was transferring a client from wheel chair to commode when she felt pain in her back. Per OMNI, she sustained strain to back and left wrist.

DOI: 5/12/2015. Patient is a 57-year-old male crane operator who sustained injury when he felt pain in his lower back from moving multiple outrigger pads weighing approximately 80 pounds each. Per OMNI, he was diagnosed with lumbar strain. He is status post lumbar laminotomy at L3-L4 and L4-L5 on 03/01/2016

Based on progress report dated 06/16/15, the patient complains of increasing right greater than left hand pain, numbness and weakness. He also reports of continued bilateral foot pain.

Based on the progress report dated 10/17/16, the patient complains of constant pain in his head and neck, rated as 5/10. He also reports frequent headaches.

DOI: 2/15/2014. Patient is a 61-year-old female clinical specialist who sustained injury to her back and left knee when she was involved in a motor vehicular accident. Per OMNI, she was initially diagnosed with grade 1 L4-5 lumbar spondylolisthesis with left paracentral disc protrusion and left L5 radiculopathy.

Based on the medical report dated 10/27/16, the patient rates her pain with medications as 4/10. Her activity level has increased.