Examination Report On High Back Pain Essay

HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weighed approximately 40 pounds. Around the first of January this year she began to complain of back pain that

Patient has been previously denied with 60 Tablets of Diclofenac Sodium XR 100 mg and 90 Tablets of Cyclobenzaprine 7.5 mg on 05/17/16 (Review 261084).

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.

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

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.

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

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

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

Mr. Reid said he needs help changing positions, moving his legs, stand by assistance to supportive assistance when walking due to legs giving out. He uses a cane and a borrowed scooter. He needs help with dressing, bathing, cleaning, home maintenance, and yard work. He

This is a 52-year-old male with a 8/21/2014 date of injury. IW is a milker, who was pushing cows, when one backed

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

The x-rays of Plaintiff’s spine showed normal alignment, no swelling, no fracture or dislocation and normal lordosis of the cervical and lumbar spine. Plaintiff’s left knee x-ray also showed no fracture or dislocation, but moderate decrease in the meduial articular joint space. Plaintiff was given a general diagnosis of neck pain, back pain, low back pain and left knee pain. Plaintiff was prescribed 3 sessions per week for 6 weeks of physical therapy.

The evidence in file shows the claimant has a history of back, shoulder and leg pain. He was seen 4/11/17 in the emergency room. He complained of back pain. His gait and the rest of the physical exam was grossly was normal At the internal medicine consultative exam (IMCE) on

This is a 46-year-old female with a 10/10/2012 date of injury, due to a cumulative trauma to the neck, right shoulder, right wrist and hand.

Stand and gait is normal, pain in dermatome L5 and S1 both side , local pain in the lower lumbar area , sensation intact ,no muscle weakness , reflex status normal .