DOI: 01/25/2015. The patient is a 30-year-old female housekeeper who sustained a work-related injury to her knee and low back when she slipped and fell on furniture polish that was spilled by a co-worker. Per OMNI, she is diagnosed with lumbar sprain/strain.
Per the medical report dated 1/20/16, it was noted that the patient has completed 6/6 PT sessions on 12/17/15, and has had 2/8 acupuncture sessions.
Based on the progress report dated 08/15/16 by Dr. Fernandez, the patient rates her pain with medications as 3/10, and without medications as 8/10. Quality of sleep is good. Her activity level has decreased. Patient has low back pain referring to the right foot. The patient notes that she has difficulty climbing up and downstairs, bending, …show more content…
At L5-S1, there is a broad based disc bulge, with superimposed right paracentral disc extrusion extending below the level of the disc, impinging against the transverse right L5 nerve root to the lateral recess. Epidural lipomatosis is seen, causing severe central canal stenosis, with disc bulge causing mild bilateral neuroforaminal.
IW was diagnosed with other lumbar region intervertebral disc disorders, right sided sciatica, other muscle spasms and spondylosis without myelopathy or radiculopathy, lumbosacral region.
EMG/nerve conduction study will be ordered to quantify the extent of the sciatica down the lower extremity. This may help identify the extent of right L5 radiculopathy that she is currently suffering from. Epidural injection will also be considered after the EMG is received to provide more objective information for her history.
Patient has been previously denied with same request on 03/28/16 (Review
Per the medical report dated 1/20/16, it was noted that the patient has completed 6/6 PT sessions on 12/17/15, and has had 2/8 acupuncture sessions.
Based on the progress report dated 08/15/16 by Dr. Fernandez, the patient rates her pain with medications as 3/10, and without medications as 8/10. Quality of sleep is good. Her activity level has decreased. Patient has low back pain referring to the right foot. The patient notes that she has difficulty climbing up and downstairs, bending, …show more content…
At L5-S1, there is a broad based disc bulge, with superimposed right paracentral disc extrusion extending below the level of the disc, impinging against the transverse right L5 nerve root to the lateral recess. Epidural lipomatosis is seen, causing severe central canal stenosis, with disc bulge causing mild bilateral neuroforaminal.
IW was diagnosed with other lumbar region intervertebral disc disorders, right sided sciatica, other muscle spasms and spondylosis without myelopathy or radiculopathy, lumbosacral region.
EMG/nerve conduction study will be ordered to quantify the extent of the sciatica down the lower extremity. This may help identify the extent of right L5 radiculopathy that she is currently suffering from. Epidural injection will also be considered after the EMG is received to provide more objective information for her history.
Patient has been previously denied with same request on 03/28/16 (Review