Informatic Cancer Case Study Ppt

MRI of the lumbar spine obtained on 05/19/15 revealed at L2-3, endplate osteophyte formation and disc bulge contribute to a mild degree of spinal canal stenosis and a mild degree of bilateral neural foraminal compromise. At L3-4, a disc bulge eccentric leftward and endplate osteophytes formation are responsible for a mild degree of spinal canal stenosis, a mild degree of right neural foraminal encroachment, and a moderate degree of left neural foraminal encroachment. At L4-5, there is a diffuse disc bulge and endplate osteophyte formation which effaces the ventral aspects of the thecal sac and are responsible for a moderate-to-severe degree of spinal canal stenosis, a mild degree of right neural foraminal encroachment, and a severe degree of left neural foraminal encroachment. At L5-S1, a shallow disc bulge and endplate osteophyte formation contribute to a mild degree of left neural foraminal encroachment, without compromise of the spinal

CT scan of the cervical spine dated 01/07/14 revealed posterior fusion from C5 through C7. There is minimal anterior subluxation of C6 on C7.

Scharf utilized Diagnosis Related Estimate cervical category II and assigned an 8% Whole Person Impairment. Dr. Scharf noted the MRI study of the cervical spine right disc extrusion at C5-C6, but there are no verifiable radicular symptoms in light of the result of the EMG/NCV studies, despite the applicant’s subjective complaints of radicular symptoms into the bilateral upper extremities. Since there are no verifiable radicular symptoms, the placement into DRE category II seems appropriate.

Dr. Abiera had reviewed a September 3, 2010 MRI of the cervical spine that revealed central protrusion/herniation at C3/C4, left paracentral protrusion/herniation at C7/T1, Disc bulges C4/C5, C5/C6 and C6/C7, left paracentral extrusion/herniation at T3/T4 and straightening of cervical lordosis. In addition, Dr. Abiera noted an August 11, 2010 x-ray of the cervical spine which revealed blastic lesions, incidental Clay Shovelers Fractures of C7 and an August 11, 2110 x-ray of the thoracic spine which was

Is the request for 1 Anterior Cervical Discectomy with Fusion at the C5/6 Level between 9/8/2016 and 11/7/2016 medically necessary?

cervical discectomy and fusion performed on 04/14/15. The latest progress report noted that the patient has neck pain, upper back pain, and shooting pain down the arms. The exam revealed that the DTRs were mildly diminished in the left upper extremity. The strength and sensation were mildly diminished in the left upper extremity as well. Spurling sign was also weakly positive on the left. It is noted that the patient has tried and failed conservative treatment, including medications and PT. However, review of the records revealed that the postop PT was put on hold due to his increased pain. In addition, the MRI Report showed that the disc space was normal and there was no significant disc herniation at the requested level i.e. C7-T1. The spinal canal and neural foramen are patent. In addition, EMG Report revealed that there was no evidence of peripheral nerve entrapment or underlying peripheral neuropathy on nerve conduction studies. Considering the minimal/mild physical examination findings and normal imaging and EDS testing; the medical necessity of C7-T1 cervical ESI has not been established. Recommend

Patient has been previously denied 1 Transforaminal Lumbar Interbody Fusion at L4-L5 Level on 09/09/15 (Review

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.

It has exhibited red flags that warranted me to evaluate further and seek referral. Though it is not frequent. I am always on my toes on the lookout for anything that I find suspicious in the pathological presentation during my initial touch point with the patient. Red flags can be determined and brought to light during history and physical examination, such as patient demographics, social and health habits, medical/surgical history, medications, family history, systems review, and review of systems, physical therapists have the examination data necessary to identify the need for medical referral (Ross and Boissonnault, 2010, p. 682). A detailed history assessment preceding trauma and cervical spine tenderness with notable limitation of motion prompt consideration for immediate immobilization, referral to a specialist, and further investigation utilizing diagnostic imaging. Red flags can be used as a tool to verify the diagnosis during evaluation. However, there are times that during initial imaging, patient doesn’t exhibit any signs of red flags. That is why it is therapist responsibility to take note of all the possible symptoms that might need urgent investigation to prevent further

On 7/15/16 I met Ms. Pletscher in the office of Dr. Easton. Ms. Pletscher had a cervical fusion on 6/15/16. Ms. Pletscher was driven to the appointment by her daughter. She was wearing a hard aspen collar. X-rays taken showed that there was good alignment with her hardware. She may now be fitted for a soft collar. The incision is well healed with no signs of infection. She will be allowed to start physical therapy after 7/29/16. An operative report was obtained. Ms. Pletscher had a list of questions. She is concerned about the left shoulder being lower than the right; she also said that it doesn’t seem to be tracking. I did point out that she had already been evaluated by an orthopedic surgeon and the MRA of the shoulder was fine. She agreed

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.

12/01/15 Progress Report noted that the patient has cervical spine pain. Examination of the cervical spine revealed tenderness noted over the paraspinal and trapezius muscles. However, the exam revealed no discrete tender points or twitch responses on palpation over the neck. In addition, the latest report does not show any sensory or motor deficits. Furthermore, the PT reports available for review indicate that the therapy was done for bilateral hands and wrists. There is no documentation of the attempt of physical therapy of the cervical spine. There is no clear documentation of the failure of aggressive conservative treatment around the cervical spine. In addition, the request is for 15 injections and the guidelines do not support more than 3-4 injections per session. Therefore, the medical necessity of trigger point injections X 15 has not been substantiated. Recommend

MRI of the lumbar spine obtained on 07/15/08 showed post-surgical changes at L4-5 and L5-S1, multilevel degenerative changes, most prominent at L4-5 and L5-S1, and foraminal narrowing at L4-5 and L5-S1.

Based on the medical report dated 01/05/17, the patient presents for follow-up of his cervical strain. He states that he feels better. He has finished up his first round of therapy session. He requests more therapy.

The patient received comprehensive adjustments to sections of vertebral and occipital subluxations. The patient made continuous advances throughout the care, the symptomatic primary reaction to care was optimistic. Subluxation appears to be associated with cervical trauma.