Lumbar Discomfort Case Study

It was noted that the random urinary drug screen dated 6/14/16 (no official report) is consistent with medications. Controlled Substance Utilization Review and Evaluation System (CURES) dated 8/1/16 from department of Justice (no official report) found to be consistent with the medications. The pateint also has opioid agreement signed 7/14/16 and a grade of 3 on opioid risk assessment. The 4 A’s of opioid monitoring notes that Norco and Neurontin notes that were not prescribed in the past and do not have significant documentation to provide functional improvement.

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

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

As per medical report dated 3/10/2016, patient complains of low back pain rated at 7/10 with left lower

Leg pain has resolved after lumbar ESI, but back pain did not change. It has been present for months. IW has persistent symptoms and symptoms have improved since treatment. It is reported as aching, deep and stabbing pain, only on the left side. It is worse during the morning and has more pain and stiffness. Symptoms are aggravated by twisting and back extension. Transcutaneous electrical nerve unit helps. IW reports associated paresthesias and weakness, not often. IW has had PT, which offered no help. IW would like to proceed with lumbar ESI. Pain is rated as 6/10.

On examination of the lumbar spine, there is moderate to severe muscle spasm and tenderness of the paraspinal muscles and spinous process at L4-5. There was painful active

The ROM was restricted, 50% of normal. The paraspinal muscle strength and tone was normal. The SLR was negative bilaterally. The exam of the left lower extremity was normal. The exam of the right lower extremity was normal except mild decreased strength in the right hip flexors. A reported MRI Lumbar Imaging on 07/01/15 showed multilevel degenerative changes; Previous L4 to sacrum fusion, evidence of herniated disc or significant central stenosis or foraminal stenosis. A reported MRI L Spine on 11/05/15 revealed herniated disc L2-3 with inferior extrusion impinging on the right L3 nerve root. Assessment: The patient has continuing symptoms of pain in the right lower extremity radiating down along the anterior thigh. This is consistent with the herniated disc at the L2-3 level on the right. He had previous surgery at the L2-3 level 3 years ago for his work-related

There is tenderness to palpation over the entire lumbar paravertebral region bilaterally, left greater than right. Deep tendon reflexes are 1 + and symmetrical at the patellar and 1+ to the left Achilles and absent right Achilles.

The patient is a 62-year-old male with a long history of cervical and lumbar pain secondary to degenerative disk disease and spondylosis. He also is noted to have multiple other problems including a fairly severe left rotator cuff arthropathy which does require surgery on the left. It is important to note that this is important because the patient has been wheelchair bound since 2013 and now has difficulty with ambulation. He also has a history of prior cervical decompression in the remote past at C3-4. The patient complains of both cervical and lower extremity pain as well as radiating symptoms in the left upper extremity all the way down into the level of the hand. He denies

Based on the progress report dated 12/16/15, the patient reports that the pain remains in the low back and bilateral shoulders. The low back pain radiates to the bilateral lower extremities and is associated with numbness and tingling. He has worsening leg symptoms. He has not yet been authorized for his lumbar ESI. Surgery is pending for the left shoulder.

The case that was selected is John Doe 91 years old male has a history of end stage renal failure, osteoarthritis, falls, and past surgeries. Norco 10-325 prn q 4 hours, tylenol 650 q 6 hours, restoril 15mg at bedtime was prescribed to control the patient’s pain

DOI: 5/12/2015. Patient is a 57-year-old male crane operator who sustained injury when he felt pain in his lower back from moving multiple outrigger pads weighing approximately 80 pounds each. Per OMNI, he was diagnosed with lumbar strain. He is status post lumbar laminotomy at L3-L4 and L4-L5 on 03/01/2016

Based on the medical report dated 09/19/16, the patient complains of unchanged pain to his low back, abdomen, right groin, and pelvic region. He also reports insomnia, associated with ongoing pain.

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.

Pain is noted with lumbar extension. Tenderness is noted in the right L4-5 and L5-S1 facet joints. Patient was diagnosed with lumbar spondylosis and chronic pain syndrome.