Gunderson Case Summary

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

Range of motion shows flexion of 85 degrees, extension of 30 degrees, and lateral tilt of 25 degrees bilaterally. Straight leg raise is positive on the right at 90 degrees for low back pain. Bechterew's test is positive on the right. The patient has diminished sensation in the right L4, L5 and S1 dermatomes. Deep tendon reflexes are absent in the right knee and right ankle.

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.

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.

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

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.

She reports tenderness to the posterior aspect of the cervical spine, trapezius region and scapular region with deep palpation.

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.

Based on the latest medical report dated 02/10/16, the patient has undergone extensive PT. She was diagnosed with sprain/strain derangement of the cervical spine, cervical subluxation complex, and cervical brachial radiculopathy, sprain/strain derangement of the lumbar spine, lumbar subluxation complex and lumbar radiculopathy.

On March 25, 2016 a 45 year old male patient came in to Mount St. Mary’s Hospital to have x-rays done of his cervical and lumbar spine, hip, shoulder, sacrum and coccyx. The patient indicated that 16 years ago he woke up with a stiff neck that never went away. Along with his stiff neck, the patient stated that he was experiencing lower back pain as well for the past 16 years. The patient also specified that recently he had started suffering from pain in his right hip and right shoulder. When asked, the patient stated that he had not had any injuries to cause the pain. The patient also indicated that he had never had any surgeries to his lower back or neck. For this case study we will only be looking at the images of his cervical and lumbar

11/25/15 Progress Report described that the patient has moderate to severe pain in his lumbar spine. The pain is 5-6/10-scale level. It is radiating, to his right leg; associated with stabbing; aching and sharp. There is limited ROM due to pain, with stooping, bending, lifting, pushing, pulling, carrying, walking, standing, sitting, ascending and descending stairs. The patient reported difficulties performing his ADL. The patient also reported sleeping problems. The patient is not working since is injury. The patient is currently taking Advil 200 mg an ibuprofen. Exam of the lumbar spine revealed tenderness to palpation over the

Based on the medical report dated 02/26/16 by Dr. Skubic, the patient complains of constant sharp aching pain in his lumbar spine, rated as 7/10. The pain is aggravated by bending, twisting, lifting, and prolonged walking/standing and is alleviated by modified activity. The patient has difficulty performing activities of daily living (ADLs) which include dressing, standing, sitting, climbing stairs, walking, lifting, restful sleeping and driving. Treatments to date includes medications, nonsteroidal anti-inflammatory medications (NSAIDS), 5 PT sessions which did not help, braces and activity modification.

DOI: 3/18/2016. Patient is a 31-year old female who sustained a work related injury to the lower back. The patient was subsequently diagnosed with strain of muscle, fascia and tendon of lower back, initial encounter. As per medical report dated 4/7/16, patient returns for recheck of injuries. The patient states she is not feeling better. Patient has been referred to physical therapy. On the review of system-musculoskeletal, back pain was noted. Lumbosacral spine shows tenderness at L2 to L5 at the left paraspinal (muscular, paraspinal L2, L3 and L4) and right paraspinal (muscular, paraspinal L2, L3 and L4).