Gastritis Case Studies

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.

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

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.

Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is

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

The patient was advised to take less medication and start weaning herself off of it as possible, and this is all in due to protect her kidneys and liver function and also a second prescription was given for Norco 10/325 one tablet twice daily #60 with "Do Not Refill or Do Not Dispensed Until 11/06/2016. The patient is to continue going to the gym and working on her stretching and strengthening exercises. Acupuncture 2 visits a week for 4 weeks for a total of 8 visits for her right shoulder is also requested, since she is starting to get more pain and this is limiting her activity such as vacuuming, and she is taking more medications because of increased pain. POMI (Patient Opioid Misuse Index) score shows 1/6, indicating the patient is not a potential misuser of

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

Based on the latest follow-up evaluation progress report dated 03/02/16, the patient complains of right shoulder pain and stiffness. He states that his shoulder feels sore. He states that his pain is aggravated by the cold weather and over activity. The patient has not attended physical therapy for some time due to travel outside of the country. He is using an analgesic cream.

02/09/16 Progress Report noted that the patient has neck pain, upper back pain, and shooting pain down the arms. The pain is on the left side. It is rated as 3-4/10. It is stabbing, burning, and pins and needles. Medications and rest alleviate the pain. Work, standing, walking, and activity aggravate it. The patient has tried muscle relaxants, strong pain meds, PT, hot packs, and ice, all of which have helped, but he continues to experience substantial pain. The exam revealed that the DTRs were mildly diminished in the left upper extremity.

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.

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 pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

S: Aerotek TM is in HMMA Medical Clinic to follow up with Low Back strain with lumbar radicular pain that radiates down to back of his RIGHT HEEL. According to TM the incident occurred on 6/14/17. TM’s initial radicular pain was down to his left leg but now it is down to his right leg. According to TM for the past 6 weeks he hasn’t done nothing but raying around the house, and his back is not getting batter.

On the statement of medical necessity per MG-2 form dated 07/13/16, patient has been experiencing severe lumbar spine pain/spasms since the injury. She complains of lumbar spine pain with cramps in the lower extremity going down to the feet, associated with tingling sensation. There is left greater than right L3-S1 pain and spasms, left greater than the right L3-4, L4-5 and L5-S1 facet joint pain, upon posterolateral extension at 45 degrees. There is bilateral sacroiliac joint tenderness. There is tenderness over the right lateral quadriceps muscle. Range of motion (ROM) is limited secondary to

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 .

The gastrointestinal tract contains the esophagus, stomach, small intestine, and the large intestine. Each of these have a specific job/function to do, and when parts of the GI system don’t work as they should GI disorders can arise. Stress can be defined as “a state of mental or emotional strain or tension resulting from adverse or very demanding circumstances” (Merriam-Webster Dictionary).