Multilevalgia Rheumatica Case Study

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DOI: 12/20/2010. Patient is a 63-year-old female compliance support specialist who sustained a work-related injury when she slipped and fell on wet tile floor. Per OMNI, she strained her left wrist, left shoulder and neck. Based on the progress report dated 03/17/16, the patient presents with the same complaints of lower back pain bilaterally and lower extremity numbness and tingling and at times pain shooting down into the Lower extremities, bilaterally. She has been sleeping okay though now since she has been taking Elavil at night as needed. On examination of the lumbar spine, there is mild paraspial lumbar muscle tenderness to deep palpation. There is a questionable facet joint tenderness to deep palpation. There is decreased sensation to touch in the distribution of the L5-S1 dermatomes in bilateral lower extremities.…show more content…
As of this report, an MRI done on 03/14/16 showed multilevel lumbar spondylosis. No significant central canal stenosis was noted. There were few areas of neural foraminal stenosis secondary to disc bulging and mainly bilateral facet
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