Low Back Pain Case Summary

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.

Based on the progress report dated 03/02/16 by Dr. Ozaeta, the patient has had a right knee corticosteroid injection one week ago. She had to take a Norco yesterday for right knee pain. She saw Dr. Cantrell, who requested 8 additional physical therapy sessions. She has low back discomfort, notable when sitting. She takes nortriptyline and an antihypertensive.

Per the medical report dated 07/18/16, patient is being seen for her lower backache, rated 7/10 with medications and 10/10 without medications. Current medications include Ambien 10mg; Maxalt-MLT 10mg; Norco 10/325mg; Evzio 0.4mg; orphenadrine 100 mg and gabapentin 600 mg.

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

Per progress report dated 8/12/16, the patient was seen for her chronic neck pain and bilateral wrist pain. Current medications include Norco, Neurontin, Lisinopril, propranolol, clonazepam, fexofenadine, Asmanex, Nasonex, Relpax, Prozac, and Patard.

On examination of the right shoulder, there is pain on range of motion. Abduction was 160 degrees. Forward flexion was 165 degrees.

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 progress report dated 12/10/15, the patient reported that she is taking tramadol with good relief and tolerating it well. She states that her pain levels are 6-7/10 without medication and 3-4/10 with medication.

On examination of the back, there is slight to moderate pain to palpation of the right paraspinous muscles of the low back. Palpation reveals equivocal muscular spasm. The bilateral patellar and ankle reflexes are 0+.

Based on the medical report dated 03/30/16, the patient has had pain in the right lower leg, numbness and tingling on the left side as well, rated as 8-9/10.

As of this report, last urine drug screen, Controlled Substance Utilization Review and Evaluation System (CURES) and Pain contract were dated 01/29/14.

Based on the medical report dated 12/13/16, the patient presents for follow-up. Lumbar discomfort is described as sharp, aching, burning, shooting, severe and continuous, comes and goes, discomfort, pain, random, varying with activity, increasing with movement, tightness, and throbbing. It is rated as 9/10 without medications and 6/10 with medications. The symptoms are aggravated by changing positions, lifting, pulling, pushing, carrying, sitting, twisting,

As per the orthopedic consultation report dated 08/31/15 by Dr. Phillips, the patient complains of constant right-sided low back pain. It is associated with swelling. It radiates to the right leg. She is unable to perform her activities of daily living due to pain. There is constant right leg pain. As of this report, MRI of the lumbar spine dated 8/11/2014 showed straightening of the lumbar lordosis, and mild broad base bulging annulus at the L4-5 level with a left paracentral bulging annulus extending into the neural foramen producing mild central stenosis and mild left-sided foraminal stenosis but these appear to be chronic changes. No acute epidural lesion or acute disc