DOI: 12/15/2015. The patient is a 34-year-old male bulk loader who sustained a work-related injury to his lower back and right knee after a door frame and double doors collapsed. Per OMNI, patient was initially diagnosed with laceration to right knee and lower back pain.
MRI of the lumbar spine dated 04/11/16 demonstrated left paracentral disc protrusion at L4-5 resulting in moderate central canal stenosis and bilateral foraminal narrowing. Correlation with bilateral L5 radicular symptoms is recommended. There is also a broad-based disc bulge at L5-S1 resulting in bilateral foraminal narrowing.
Based on medical report dated 6/6/2016 by Dr. Steiner, patient complains of constant pain across the lower back. He reports occasional right leg pain radiating to the right calf. He reports recurrent pain along the along the medial side of his right knee. He also reports occasional cracking in the right knee and occasional right hip pain. Current medications include meloxicam, …show more content…
Boucree, the patient has continued complaints of back pain with associated leg radicular pain, right greater than the left. The pain continues to persist, interfering in his quality of life and activities of daily living. Patient also complains of persistent neck and arm radicular pain, and shoulder mechanical pain, which remains manageable. On examination, paraspinal cervical and lumbar tenderness is noted with moderate restriction of the cervical and lumbar spine, secondary to pain with active and passive range of motion with flexion, extension and bilateral lateral bending and rotation. The neurovascular exam is unchanged with 4/5 strength with right knee flexion and right external hallucis longus. Deep tendon, patellar and Achilles reflexes are ¼ symmetrically. Right straight leg raising exam is positive. Hamstring tightness is present with left straight leg raising exam. Patient was diagnosed with foraminal stenosis of the lumbar
MRI of the lumbar spine dated 04/11/16 demonstrated left paracentral disc protrusion at L4-5 resulting in moderate central canal stenosis and bilateral foraminal narrowing. Correlation with bilateral L5 radicular symptoms is recommended. There is also a broad-based disc bulge at L5-S1 resulting in bilateral foraminal narrowing.
Based on medical report dated 6/6/2016 by Dr. Steiner, patient complains of constant pain across the lower back. He reports occasional right leg pain radiating to the right calf. He reports recurrent pain along the along the medial side of his right knee. He also reports occasional cracking in the right knee and occasional right hip pain. Current medications include meloxicam, …show more content…
Boucree, the patient has continued complaints of back pain with associated leg radicular pain, right greater than the left. The pain continues to persist, interfering in his quality of life and activities of daily living. Patient also complains of persistent neck and arm radicular pain, and shoulder mechanical pain, which remains manageable. On examination, paraspinal cervical and lumbar tenderness is noted with moderate restriction of the cervical and lumbar spine, secondary to pain with active and passive range of motion with flexion, extension and bilateral lateral bending and rotation. The neurovascular exam is unchanged with 4/5 strength with right knee flexion and right external hallucis longus. Deep tendon, patellar and Achilles reflexes are ¼ symmetrically. Right straight leg raising exam is positive. Hamstring tightness is present with left straight leg raising exam. Patient was diagnosed with foraminal stenosis of the lumbar