Clinical Presentation G. J. is a 28 year-old male patient with no past medical history. On September 13, 2015, he was admitted at Kendall Regional Medical Center with a chief complaint of worsening back pain lasting for over a month. He denies any recent trauma or falls, numbness, tingling, or paresthesia.
MRI of the cervical spine obtained on 06/26/13 showed mild degenerative spondylitic changes and status post posterior fusion.
Per the PT daily note dated 05/27/15, the patient has attended 13 visits. As per medical report dated 4/19/16, a lumbar MRI with and without contrast was requested to evaluate for a discogenic and/or facetogenic etiology for pain. MRI would also allow evaluation of conditions such as spinal stenosis.
Quality of sleep is fair. Activity level has remained the same. On examination of the cervical spine, there is tenderness and tight muscle band is noted on both the sides of the paravertebral muscles. There is pain with extension and palpation of right facets.
The carrier has denied coverage of FDG-PET scan as not medically necessary. A letter from the carrier to the member, dated 05/08/2016, states in part:
We have recently received additional records from Florida Rehabilitation and Injury Center pertaining to Ms. Anne Carey. The following serves as a summary of the same. On January 4, 2011, Ms. Carey presented to Florida Rehabilitation and Injury Center with complaints of upper back and mid back pain. Ms.
Mcclurg, the patient presents for his neck pain, described as dull and aching. Treatment to date includes activity modification, acupuncture, and 9 sessions of chiropractic care. Condition is improving. Current care has provided 70% pain relief. Of note, MRI of the cervical spine dated 3/25/2015 revealed C5-6 discogenic spondyloarthropathy with mild central canal stenosis and mild bilateral C4-5 facet arthrosis.
MRI of the cervical spine dated 08/17/16 showed at C3-4 and C4-5, there is mild posterior disc bulging.
95941- Intraoperative Monitoring 95938 - Upper & Lower SSEP 95870 - EMG 1 extremity (4 muscles or less) 95927 - Cortical SSEP4 95861 - EMG2 Extremity (5 muscles or more) 51785 - S-EMG (Anal Sphincter) 95937 - Train of four 95813 - EEG /Non Intracranial 10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on
Dr. Adams reviewed the MRI films. The family found a man who makes custom cervical collars in Florida and they asked for a order so they could try and have one made. Dr. Adams said he is more concerned about the Kyphosis. He asked if the collar had been removed. Mr. Messing said he thought the collar could be removed, Ms. Messing said it has not been removed. Dr. Adams said a custom collar is not the solution, he feels she needs a Halo. He said he doesn’t do those any longer. He recommends Henry Ford, Beaumont or the U of M hospital. He ordered a new ct scan to be done. While were in the exam room Mr. Messing called his daughter a nurse practioner and Dr. Adams spoke with her. She will speak with the neurosurgery department at her hospital and find the appropriate doctor. I spoke with Gail after the appointment as she had requested and provided her with an update. Gail had requested an open claim letter so she could make arrangements for her mother to see her neurologist and her PCP but needs a open claim letter. The letter was obtained and faxed to Dr. Kala
Conservative treatment notes included aquatic physical therapy, acupuncture, narcotic pain medications, Transcutaneous electrical nerve stimulation (TENS or TNS), psychologist, and hypnosis. The patient also has tried and failed multiple over-the counter and prescription remedies for her opioid induced constipation including diet modification, stool softeners, and laxatives including Miralax, Senokot, Metamucil. Ducalax. It was noted that Movantik is being provided to help her with this situation. As per interval changes, the patient complains of ongoing neck and left upper extremity pain, and an increase in low back and left lower extremity pain. Patient states that she fell at home 2 weeks ago. She states that she injured her right arm and it has been swollen for 2 weeks. The pain score is 10 without medications and 2 with medications. The medications prescribed are keeping the patient functional, allowing for increased mobility, and tolerance of activities of daily living, and home exercises. Current medications incldue Nucynta, Percocet, Restoril as necessary for insomnia, Cymbalta, Neurontin, Cselebrex, Robaxin, Prilosec, Singulair, Vagifem, and
DOI: 8/24/2008. Patient is a 55-year-old female manager who sustained injury to her neck and back when she slipped and fell while walking down a set of pull out stairs. Per OMNI, she is diagnosed with cervical strain with radiculopathy and lumbar radiculopathy. She underwent C5-6 partial corpectomy and fusion in 05/31/2011.
DOI: 6/16/2015. Patient is a 67-year-old male role player who sustained injury when he was picked by soldier while role playing and carried up a hill. Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck
12/19/15 MRA Report demonstrated no focal stenosis or aneurysm in the intracranial vasculature. 12/16/15 Progress Report indicated that the patient wakes up with headaches. She mentioned headache in the frontal vertex or temporal occipital areas. She also feels imbalance. She denies bruxism and has no significant neck symptoms. She reported having some minor neck tightness. She was being treated with acupuncture 2 X per week and craniosacral therapy 2 X per week. She noted that she was able to read better in the past two weeks. She had difficulty scanning a written page in the past. She also mentioned that her insomnia has slightly improved since initiating these 2 therapies. Physical exam showed no palpable spasms in her cervical region over her muscles of mastication. Cervical range of motion: backward flexion 70 degrees and forward flexion 60 degrees. She was able to turn 60 degrees to each side. She is able to tilt 40 degrees to other side. Comments: Based on the absence of objective findings, she has reached a medical end result with no need for any further treatment. No additional treatment or diagnostic testing is
You have raised a thought provoking question. This is the type of inquiry that we should be particularly keen when it comes to our profession. To reiterate my reply from yesterday’s discussion post addressed to Jinky as physical therapists we are expected to possess an excellent skills set