Ceervical Spondylosis Case Summary

Per progress report dated 8/12/16, the patient was seen for her chronic neck pain and bilateral wrist pain. Current medications include Norco, Neurontin, Lisinopril, propranolol, clonazepam, fexofenadine, Asmanex, Nasonex, Relpax, Prozac, and Patard.

Based on the progress report dated 03/01/16 by Dr. Ahmed, the patient continues to complain of constant lower back pain radiating to her left leg which she describes as sharp with pins, and needles and intermittent numbness and weakness.

Based on the progress report dated 04/05/16 by Dr. Fieser, the patient complains of pain in the left knee, left ankle and left foot, associated with numbness and tingling in the left leg/foot, as well as weakness in the left leg. He describes the pain as sharp, cutting, throbbing, dull, aching, pressure-like, cramping, shooting and shocking with muscle pain and pins-and-needles sensation.

Per medical report dated 11/4/16, the patient’s medications include Ultracet 37.5/325 mg, Lodine 400 mg twice a day (on hold until April 2017) and Zanaflex 4 mg twice a day.

01/06/16 Pain management Report described that the patient has a history of chronic low back pain and right lower extremity pain. The patient has a spinal cord stimulator since 01/30/15. The patient visited today for follow-up and medication refill. He reported that his pain has been stable since the last month. His pain is 5/10-scale level with the use of medications and 8/10-scale levels without the use of medication. The patient reported that the medications, activity restriction,

02/09/16 Progress Report noted that the patient’s current medication regimen provides moderate pain relief without any adverse effects. The patient stated that he has seen Dr. Smith for IT pump clearance and would like to proceed with the trial. He has chronic lumbar back pain. The pain radiates the left buttock, left posterior thigh, left lateral thigh, left lower leg, left foot, and right lateral thigh. The patient describes the pain as sharp, dull, aching, bumping, stinging, and throbbing. The onset was sudden immediately after the injury. The symptoms are constant and the episodes occur daily. The symptoms are described as severe and worsening. Back motion, lifting, and bending exacerbate the symptoms. Associated symptoms include leg numbness, foot numbness, leg weakness, and foot weakness. Current treatment includes opioid

Based on the latest follow-up physiatric evaluation report dated 01/11/16, the patient complains of lower back pain which improves temporarily with PT but continues to radiate to his left leg with numbness, tingling and weakness. He attends PT three days per week and participates in a daily home exercise program.

Based on the progress report dated 03/28/16, the patient complains of pain to his lumbar

Current medications include naproxen sodium, Prilosec, metformin, losartan, methotrexate sodium injection solution, folic acid, aspirin, Os-Cal 500 + 03 500 mg, metoprolol tartrate, Norvasc and Lyrica.

01/15/16 Progress Report noted that the patient has lower back pain and left leg pain. It was noted that the provider spoke with the patient over the phone. He has continuing pain in the right lower extremity. The epidural injections have been denied. He has a herniated disc on the right L2-3. He has been suffering from symptoms in the right leg for the last 5 months. He cannot tolerate the pain. He would like to pursue surgery. The examination of the thoracic spine was normal. The exam of the lumbosacral spine showed that all musculature

Based on the progress report date03/16/16, the patient has been managed conservatively with PT and has continued to experience discomfort. His pain has migrated from primarily thoracic to more localized lumbar pain.

The patient is a fifty-six-year-old male who was admitted on 10/3/16. His reason for admission was his involvement in a motor vehicle accident where his car was t-boned by another vehicle. Upon arrival to the emergency department, his chief complaint was his inability to detect sensation from the nipple line down, and his inability to move his extremities. He was otherwise alert, oriented and able to breathe on his own. After an assessment confirmed his inability to feel anything from the chest down, a portable x-ray of his chest was ordered, but this did not show any acute findings. Multiple computed tomography scans were then ordered for his head, cervical spine, abdomen and pelvis, chest and thoracic spine; but all of these scans resulted in no acute findings. However, a computed tomography scan of the lumbar spine did show spinal stenosis secondary to disc protrusion, and magnetic resonance imaging scans were then ordered for the cervical, thoracic, and lumbar spine. The magnetic resonance scans showed multiple compression fractures from the C3 to C5 vertebrae, with ligament injuries from C5 to C7, bruising of the spinous process of C6, mass bone bruising and soft tissue injuries at C3 and C4 with edema, severe spinal stenosis with cord compression at C3 and C4, and cord contusion at T2. The patient was then

Per the PT note dated 12/23/16, the patient has attended 4 sessions. Patient has less pain overall, but a voiding cervical spine mobility with flexion and extension.

On examination, he has 4-5/5 strength throughout the bilateral lower extremities. Sensation is intact to light touch throughout the bilateral lower extremities. He has tenderness over the lumbar paravertebral musculature bilaterally. He has pain with flexion and extension of the lumbar spine. He has a positive slump and straight leg bilaterally.

Based on the progress report dated 03/03/16, the IW’s medications include Lidoderm patch, Neurontin, Prilosec, Flovent, Fentanyl patch, oxycodone and Baclofen.