Patient: A Case Study

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.

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

Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last

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

Based on the medical report dated 04/14/16, the patient presents for medication maintenance. He reports ongoing pain, withdrawal symptoms such as increased pain,

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.

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.

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

At today's visit she is found in her room sitting in her recliner. She reports chronic, intermittent, dull, achy, lower back pain. Her current pain regimen is effective for her pain according to the facility staff. The staff reports that the patient is sleeping more hours during the day. She has increased generalized weakness. No acute distress noted this visit.

Based on the medical report dated 03/31/16 by Dr. Schonwald, the patient reports pain in his low back, left lower extremity, right lower extremity, as well as in his left hand that originates at his left elbow and to his fingertips.

Based on the medical report dated 01/20/16, the patient reports that his low back pain is rated as 9/10 into the right lower extremity. It’s experienced between 76% and all of the time he is awake. Some of the patient’s daily activities are being prevented by this symptom. He reports numbness and tingling in his right lower extremity.

He was prescribed with the following: Neurontin 600mg 3 tablets daily #90 as it decreases numbness, improves walking and activity tolerance and has no side effects; Zanaflex 4mg, 1 tablet daily as needed #5; Zohydro 10mg, 1 tablet daily #30 with 1 refill as it decreases pain from 9/10 to 6/10, improves walking and activity tolerance, no side effects, no abuse or aberrant behavior, consistent urine drug screen, signed medication agreement and receives pain medication from a single provider; Norflex 100mg, 1 tablet daily as needed #25 with 1 refill as it relieves muscle spasm episodes which allows for increase in walking, exercise, and activities of daily living; Vistaril 25 mg decreased to 1 tablet at bedtime #25 as it improves sleep and increases daytime activity tolerance (2 months supply). Patient will follow-up in 2

Per medical report dated 10/26/15 by Dr. Parsioon, the patient was initially seen on 9/14/15 for evaluation and treatment of cervical pain. At that time, he had neck pain without radiculopathy and bilateral hand tingling. IW stated that physical therapy made his neck pain increase and he wanted to make sure that it is okay to continue this. His chief complaint is pain in his neck radiating to the right shoulder and arm. He states the only time he gets the tingling sensation in the hand is

Patient is a 35 year old female who presented to the ED with suicidal ideation with a plan to cut herself.The patient is from Elizabeth city. She road the bus to Greensboro and caught a cab to Asheboro to see a guy friend. The patient expressed that her friend and her were not able to find a place send some time together, so she came to the Hospital. During the assessment the patient reports feelings of depression and that she has been practicing cutting behaviors with a razor on her left arm. There were no visible cut on either arm at the time of assessment. The patient reports having really bad thoughts about harming herself and contacted the friend she was visiting and husband, which told her to go to the hospital. The patient reports a

Patient is a 28-year-old Caucasian female who presents to CRU from Abrazo Central Campus. She is GMH designated, and T19. She is currently homeless. Patient used to be on social security disability due to her hearing disability, but stated she is no longer on SSI. Per collateral, she has been on Meth for about a year now. She reports to be depressed and her primary stressor is losing custody of her kids. Patient is sexually active, and believes her partner is not faithful. Per collateral client reported to the ED nurse that she has been exposed to some STDs. Patient is deaf, and cannot understand sign language. She can read lips. She denies DTO and DTS during assessment. She also denies AVH. She will benefit from meeting with provider to discuss