DOI: 9/20/2015. Patient is a 32-year-old female certified nursing assistant who sustained a work-related injury when she felt pain in her left knee while transferring a patient.
Per the medical report dated 03/23/16, the patient presented with low back and left leg pain, lumbar paravertebral muscle spasms and medial thigh pain. He has been refractory to 12 PT visits. Current medications include tramadol, ibuprofen, loratadine and Claritin.
MRI of the lumbar spine obtained on 03/31/16 revealed a mild left lateral disc protrusion at L4-5 which causes a mild left L4-5 neural foraminal stenosis. There is lumbarization of the S1 vertebral body, with a small S1-2 intervertebral disc.
Per the medical report added 05/30/16, the patient states that her condition is still the same. There are days that she is okay and days that she is in severe pain. Symptoms include paresthesias and numbness. The pain radiates to the left lower leg (numbness and paresthesia). Pain is dull and aching. The lower leg is getting worse. She had the MRI done which showed no changes and does not correlate with symptoms. …show more content…
Supine straight leg raising tests reproduces leg pain (positive on the left side). Forward flexion is decreased and painful. Patient arises abnormally. Paresthesias are noted in the left lower leg. Gait is abnormal. Deep tendon reflexes are not intact bilaterally. The left Achilles reflex is not present. Sensation is decreased to light touch. There is numbness, tingling and weakness. The overall assessment of muscle strength and tone reveals left tibialis anterior and left gastrocsoleus of
Per the medical report dated 03/23/16, the patient presented with low back and left leg pain, lumbar paravertebral muscle spasms and medial thigh pain. He has been refractory to 12 PT visits. Current medications include tramadol, ibuprofen, loratadine and Claritin.
MRI of the lumbar spine obtained on 03/31/16 revealed a mild left lateral disc protrusion at L4-5 which causes a mild left L4-5 neural foraminal stenosis. There is lumbarization of the S1 vertebral body, with a small S1-2 intervertebral disc.
Per the medical report added 05/30/16, the patient states that her condition is still the same. There are days that she is okay and days that she is in severe pain. Symptoms include paresthesias and numbness. The pain radiates to the left lower leg (numbness and paresthesia). Pain is dull and aching. The lower leg is getting worse. She had the MRI done which showed no changes and does not correlate with symptoms. …show more content…
Supine straight leg raising tests reproduces leg pain (positive on the left side). Forward flexion is decreased and painful. Patient arises abnormally. Paresthesias are noted in the left lower leg. Gait is abnormal. Deep tendon reflexes are not intact bilaterally. The left Achilles reflex is not present. Sensation is decreased to light touch. There is numbness, tingling and weakness. The overall assessment of muscle strength and tone reveals left tibialis anterior and left gastrocsoleus of