Lumbar Back Pain: A Case Study

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 progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

12/31/15 Progress Report described that the patient has cervical spine, right shoulder, and right wrist pain. She rates her cervical spine at 8/10-scale level and frequent; right shoulder pain at 8/10-scale level; and bilateral wrist pain at 6/10-scale level. The pain is frequent and improved since last visit. Rest and medications make the pain better. Weather

Physical examination revealed that the patient’s back is less tender. There is facet tenderness over the bilateral L3-S1. There is also slight pain with limited rotation, flexion, and hyperextension. The right lower extremity is noted to be weaker. The lumbar spine examination is positive for seated straight-leg raise on the left and facet loading. As per treatment plan, the patient will be continuously evaluated for medication regimen and make alterations as necessary. It was noted that the patient states that there is continued need for his Zanaflex as necessary for flare-up of muscle spasms until he is able to start up chiropractor therapy again. He will try to discontinue the medication next month with chiropractor therapy. As per office notes dated 5/23/16, the patient’s pain level is 5-6/10. He states continued need for his Zanaflex as necessary for fare-up until he is able to start up chiropractic therapy. He continues to have neck pain with intermittent periods of sharp-stabbing pain over the right side with radiation to the bilateral upper extremities with numbness as well as associated cramping into upper extremity and into fingers. Current medications include Zanaflex, Nexium, Celebrex, and

After review of the clinical information provided by NY Presbyterian Hospital-Columbia University, the Medical Director has denied your admission to NY Presbyterian Hospital-Columbia University. It was determined that the clinical information did not justify an inpatient stay. Acute inpatient hospitalization was not medically necessary. Medicare admit diagnosis hematemesis and Abdominal pain with past medical history of chronic low back pain related to Lumbar-5 disc bulge on frequent non-steroidal anti-inflammatory medications, gastroesophageal reflux disease, prior gastritis, iron deficiency anemia. You are a 59 year old female who presented to the emergency room with a complaint of abdominal pain, nausea, and vomiting for 3 days prior to your hospital admission. You reported diffuse

This is a 22-year-old male with a 6/11/2015 date of injury. He reported injuring his lower back, June 11, 2015 while carrying a desk up the stairs to the second story.

DOI: 12/09/2000. This is a 58-year-old male sanitary engineer who sustained an injury to the low back when he fell while stepping down a ladder. Patient is diagnosed with other intervertebral disc degeneration, lumbar region. He is status post lumbar spine surgery on 05/19/2006. Per medical report dated 5/26/16, the patient complains of lower back pain which has increased since his last visit, rated as 9/10 without medication. His quality of sleep is poor and activity level remains the same. As per office notes dated 6/26/16, the patient rates his pain as 9 with medications and 10 if without medication. He states that the medication is working well and no side effects noted. CURES (Controlled Substance Utilization Review and Evaluation System)

Based on the medical report dated 12/15/16, the patient complains of constant pain to her neck, bilateral shoulders and bilateral knee/leg. Pain is described as sharp, stabbing, achy and

01/26/16 Progress Report noted that the patient presented with left shoulder pain. The pain was gradual in onset and is constant. The pain is characterized as burning, sharp, shooting, and throbbing. It radiates to the neck. She described her pain as moderate to severe. Her condition is associated with numbness in her left fingertips and weakness in her upper extremities. Any activity, movement and reaching aggravate the pain. Stretching and hot showers relieve the pain. The level of sleep has been decreased due to difficulty falling asleep. The quality of sleep is poor. She has difficulty performing her ADLs. Current medications: Meloxicam, Naproxen, and Spironolactone. Review of Systems was positive for weakness and nausea. The patient also has anxiety and depression. She has had psychiatric, psychological, or social work evaluations or treatments for problems. The physical exam of the cervical spine revealed that the ROM is restricted. There were spasms and tenderness of the paravertebral muscles bilaterally. There was also spinous process tenderness noted on C6 and C7. Tenderness is noted at the paracervical muscles and trapezius. Spurling’s maneuver produces no pain in the neck muscles or radicular symptoms in the arm. Adson’s test is negative. No signs of meningism. Cervical facet loading is negative on both sides. The exam of the right shoulder was

Since the last visit dated 5/3/16, he states that he has been doing well. He notes that the physical therapy has been going well. He notices his pain and range of motion is improving. The patient notes that at least 30% improvement with physical therapy and at least 40% improvement with Vicodin. He also notes that at least 30% improvement while on his medication. He notes that he is able to get up out of bed, keep up with his hygiene, shop, and cook. He notes overall good improvement. The pain scale is 7/10 since his last visit on 5/3/16. Cervical spine examination revealed that range of motion is restricted with lateral rotation to the left limited to degrees due to pain and lateral rotation to the right limited to degrees due to pain but with normal flexion, extension, right lateral bending and left lateral bending. On lumbar spine, there is tenderness on the bilateral paravertebral muscles. Spurling’s maneuver causes pain. Lumbar facet loading is positive on both sides. Tenderness is also noted over the sacroiliac spine. Current medications include Ambien 10 mg, ibuprofen, and Vicodin

Based on the medical report dated 05/ 2616, the patient complains of headaches and stabbing upper back and shoulder blade pain radiating to her lower back. She also has neck pain, described as burning. Pain is rated as 8/10 to the neck, lower and middle back and head. When she is on medications, her neck and mid/low back pain and her headaches reduced to a 4/10. She gets anxiety and it is related to her rapid heart rate, s which makes it feel she is in pain and this

Diagnoses include chronic intractable low back and neck pain secondary to lumbosacral degenerative disc disease. Left shoulder pain s/p arthroscopy, chronic left knee pain, chronic pain syndrome, severe neuropathic pain, depression, history of drug abuse, and chronic daily headaches.

Based on the progress report dated 09/15/16, the patient complains of pain and discomfort located over the lower back, described it as cramping, numbness and burning sensation mostly to the left leg as compared to the right. Symptoms are occasional (25-50%). Pain is rated as 6/10.

S The patient is a 54-year-old female who sustained an injury on 04/25/2012. She complained of ongoing pain in the low back and neck.

"Lower back pain is a serious matter. Pain in the lumbar/spine area can be crippling and can impact your lifestyle. It is something that shouldn't be taken lightly. Lumbar spine pain can be blamed on many things. Discomfort in the spine, elbows, knees, spinal discs and bones can be traced muscular problems, disc degeneration, herniation, and lumbar stenosis and osteoarthritis. Contemporary research shows that three out of four individuals will endure the pain and suffer from lower back pain during their lifetime. Lower back should not last more than three days. If pain persists, it's wise to consult a spinal/back practitioner. Lower back issues that linger for more than 90 days is considered chronic pain."