DOI: 2/13/2013. Patient is a 47-year old male technician who sustained injury when he slipped on ice, twisting his lower back. Per OMNI, he was initially diagnosed with lumbar sprain. He has a pre-existing L2 compresison fracture.
Based on medical report dated 06/11/15, the patient complains of headaches and severe lower back pain. He reports the lower back pain is a 7/10 and is associated-with pain and numbness radiating to both hips and thighs. The pain is worse with bending, climbing, sitting for 1 hour, and standing for 20 minutes. He is not taking any medication for pain. He had an MRI of the lumbar spine which reported an old compression fracture at L2, degenerative disc disease at L5-S1, and disc bulging at L4-5 and L5-S1. The patient did physical therapy for about 6 months. The patient also saw an orthopedic surgeon who recommended conservative treatment. He also saw a pain management physician who recommends epidural steroid injections. The patient has been unable to work since 2/13/13. …show more content…
Range of motion is as follows: flexion is 40 degrees; extension is 1- degrees; and bilateral lateral extension/rotation is 15 degrees.
He is unable to toe and heel walk due to pain. Gait is antalgic. Manual muscle testing is a 4/5 to both hips. Sensation to soft touch is decreased along the anterior and lateral aspects of both
Based on medical report dated 06/11/15, the patient complains of headaches and severe lower back pain. He reports the lower back pain is a 7/10 and is associated-with pain and numbness radiating to both hips and thighs. The pain is worse with bending, climbing, sitting for 1 hour, and standing for 20 minutes. He is not taking any medication for pain. He had an MRI of the lumbar spine which reported an old compression fracture at L2, degenerative disc disease at L5-S1, and disc bulging at L4-5 and L5-S1. The patient did physical therapy for about 6 months. The patient also saw an orthopedic surgeon who recommended conservative treatment. He also saw a pain management physician who recommends epidural steroid injections. The patient has been unable to work since 2/13/13. …show more content…
Range of motion is as follows: flexion is 40 degrees; extension is 1- degrees; and bilateral lateral extension/rotation is 15 degrees.
He is unable to toe and heel walk due to pain. Gait is antalgic. Manual muscle testing is a 4/5 to both hips. Sensation to soft touch is decreased along the anterior and lateral aspects of both