Gastritis Case Study

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

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

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.

Based on the medical report dated 01/20/16, the patient reports that his low back pain is rated as 9/10 into the right lower extremity. It’s experienced between 76% and all of the time he is awake. Some of the patient’s daily activities are being prevented by this symptom. He reports numbness and tingling in his right lower extremity.

Per the IME report on 4/28/16 by Dr. Pierce Ferriter, the patient reports that he is actively treating with physical therapy and chiropractic treatment at a frequency of 3 to 4 times per week. The patient’s diagnoses include resolved lumbar strain, resolved cervical strain, resolved left shoulder strain and resolved right knee strain. There is no medical necessity for further physical therapy, orthopedic treatment of diagnostic testing based on examination.

He reports no major changes in his condition, since his last visit. His pain is rated as 3-6/10, described as dull, hard, aching or worse. Pain is increased with sitting, standing, walking, lifting, looking up and down, turning to the sides, bending, and twisting. He is unable to work. He is very limited physically. He has to modify or avoid social and recreational activities to manage the pain. He feels like his quality of life is severely affected. His pain is 80% in the neck and 20% in the upper extremities, mostly on the

O: Slow but normal gait, sitting upright on the examination table without any support, able to get up and down without any assistance on the exam table; no grimace on his face, limited lumbar spine range of motion (per TM); no muscle spasm; no impairment of NVS; no muscle atrophy noted; intact reflexes, + 5 strength to lower and upper extremities, peripheral pulses +3, sensation intact; Straight leg test was negative.

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.

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 .

He was prescribed with the following: Neurontin 600mg 3 tablets daily #90 as it decreases numbness, improves walking and activity tolerance and has no side effects; Zanaflex 4mg, 1 tablet daily as needed #5; Zohydro 10mg, 1 tablet daily #30 with 1 refill as it decreases pain from 9/10 to 6/10, improves walking and activity tolerance, no side effects, no abuse or aberrant behavior, consistent urine drug screen, signed medication agreement and receives pain medication from a single provider; Norflex 100mg, 1 tablet daily as needed #25 with 1 refill as it relieves muscle spasm episodes which allows for increase in walking, exercise, and activities of daily living; Vistaril 25 mg decreased to 1 tablet at bedtime #25 as it improves sleep and increases daytime activity tolerance (2 months supply). Patient will follow-up in 2

On examination of the lumbar spine, there is tenderness and guarding of the paraspinal musculature. Range of motion is decreased secondary to pain.

Treatment plan includes cognitive behavioral therapy evaluation eight sessions, physical therapy for the left knee, neurologic consultation for neurologic complaints and medication monitoring program with urine drug screen.