DOI: 12/12/2014. The patient is a 44-year-old male technician-supervisor who sustained a work-related injury to his low back after pushing/pulling boxes in back of truck. As per OMNI, he was diagnosed with low back strain, potential thigh/hip strain and unspecified arthropathy involving the pelvic region/thigh.
Per operative report dated 12/07/15, the patient underwent right-sided L4-5 foraminal decompression with a right-sided L5-S1 microdiscectomy and the left-sided L4-5 decompression.
MRI of the lumbar spine obtained on 09/12/15 showed mild congenital stenosis of the spinal canal. There is narrowing of the left lateral recess at L4-5 and right lateral recess at L5-S1. There is moderate narrowing of the proximal right neural foramen at L4-5.
Based on the progress report dated 08/30/16, the patient continues to have 3-7/10 low back pain with 3-7/10 right lower extremity pain and 1-4/10 left lower extremity pain. His right lower extremity pain is worsening now. The radiating pain that the patient has coming from his back going down to his leg, may not just be coming from the right hip. He is in 3rd round of therapy for his low back. He is 8 months out from surgery. …show more content…
Patient was diagnosed with lumbago and lumbar radiculopathy. As patient is now having a flare-up, patient was dispensed with Norco #80 tablets for pain control and to allow him to do activities of daily living. Patient will also require an MRI of the lumbar spine as he has worsening right lower extremity symptoms. Directly after the surgery and over the course of few months after surgery, his bilateral lower extremity irritation has improved, up until recently where the right lower extremity is now worsening. Because of the ongoing flare-up on the right lower extremity, he will require a 4th round of PT. He will follow-up in 4-6
Per operative report dated 12/07/15, the patient underwent right-sided L4-5 foraminal decompression with a right-sided L5-S1 microdiscectomy and the left-sided L4-5 decompression.
MRI of the lumbar spine obtained on 09/12/15 showed mild congenital stenosis of the spinal canal. There is narrowing of the left lateral recess at L4-5 and right lateral recess at L5-S1. There is moderate narrowing of the proximal right neural foramen at L4-5.
Based on the progress report dated 08/30/16, the patient continues to have 3-7/10 low back pain with 3-7/10 right lower extremity pain and 1-4/10 left lower extremity pain. His right lower extremity pain is worsening now. The radiating pain that the patient has coming from his back going down to his leg, may not just be coming from the right hip. He is in 3rd round of therapy for his low back. He is 8 months out from surgery. …show more content…
Patient was diagnosed with lumbago and lumbar radiculopathy. As patient is now having a flare-up, patient was dispensed with Norco #80 tablets for pain control and to allow him to do activities of daily living. Patient will also require an MRI of the lumbar spine as he has worsening right lower extremity symptoms. Directly after the surgery and over the course of few months after surgery, his bilateral lower extremity irritation has improved, up until recently where the right lower extremity is now worsening. Because of the ongoing flare-up on the right lower extremity, he will require a 4th round of PT. He will follow-up in 4-6