Low Back Injury Case Studies

Decent Essays
DOI: 09/09/1993. Patient is a 60-year-old male supervisor who sustained a low back injury when he was rear-ended while driving to a job site. Patient is diagnosed with lumbar disc degeneration. He has a lumbar surgical history of fusion L5 to S1 and 3 back surgeries in 1994, 1997, and 2003.
CT scan of the lumbar spine with contrast done on 07/07/2014 reveals post surgical changes. There is mild central canal stenosis at L2 to L3 and L3 to L4 secondary to 3.0 mm disc protrusions and short pedicles.
Based on the medical report dated 01/11/16, the patient reports that his pain and bilateral leg weakness increased last month. He is unable to stand in the shower due to severe pain in his back and weakness in his legs. He has adequate analgesisa

Related Documents

  • Improved Essays

    Nt1310 Unit 3 Assignment 3

    • 1039 Words
    • 5 Pages

    The evidence shows the claimant has a history of morbid obesity with a BMI as high as 46. A lumbar spine MRI taken on 3/26/14 showed degenerative disc disease with multilevel mild spinal stenosis. Neuroforamina was encroaching at L5 nerve root level on the…

    • 1039 Words
    • 5 Pages
    Improved Essays
  • Decent Essays

    S/P 14 Esi Report

    • 205 Words
    • 1 Pages

    Reason for Visit: s/p 14 ESI Visit; LBP Vital Signs - B/P:122/74 Temp: Pulse: 89 Resp:18 O2 Sat 99 % S: TM completed total of 14 ESI visit, and he is here for LBP follow up. TM rates his pain at 2/10 and intermittent shooting pain to his left mid-thigh level.…

    • 205 Words
    • 1 Pages
    Decent Essays
  • Improved Essays

    On 11/15/2016, the claimant reported a return of symptoms and stated that she started having spasm while working. On 11/18/2016, the claimant complained of right sacroiliac joint pain and sacrum pain that was described as moderate and constant which was rated as 5/10. There was also mild-moderate and constant right hip pain that was rated as 4/10 as well as moderate and constant neck pain that was rated as 6/10. The neck pain was unchanged since the last visit while the pain in the right sacroiliac joint, sacrum, and right hip were getting better. Examination revealed that there was increased myospasms in the right paralumbar, right parathoracic, and right paracervical muscles.…

    • 296 Words
    • 2 Pages
    Improved Essays
  • Improved Essays

    Iw Case Studies

    • 651 Words
    • 3 Pages

    Acupuncture needling was performed on this visit, as well as gentle stretches performed after the treatment. IW will continue acupuncture and PT. Based on the medical report dated 12/29/16, the patient complains of active lumbar pain, rated 6-7/10 with active and worse right leg radiculopathy, rated 6-8/10. Right leg is noted to have weakness, with history of buckling.…

    • 651 Words
    • 3 Pages
    Improved Essays
  • Decent Essays

    DOI: 2/4/2014. The patient is a 44 -year-old male laborer who sustained a work-related injury when he was putting beams together and fell on black ice between beams from elevated surface. Per the IME report by Dr. Nathan on 7/20/15, MMI has been reached and there is no medical necessity for further PT, orthopedic treatment or diagnostic testing from an orthopedic standpoint. MRI of the lumbar spine performed on 03/18/14 showed posterocentral disc herniation as noted at the L5-S1 level, which demonstrated ventral impingement on the thecal sac as well as impingement on the intervertebral foraminal bilaterally.…

    • 419 Words
    • 2 Pages
    Decent Essays
  • Improved Essays

    Dr. Watson documented the applicant has expressed pain with the extension movement of the applicant’s lumbar spine. As for the applicant’s activity of daily living, Dr. Watson did not explicitly indicate what has caused the effect on the applicant’s activities of daily living. In conclusion, Dr. Watson did not believe the applicant is considered permanent and stationary and recommended additional treatment, including physical therapy, acupuncture, chiropractic treatment, and other medications. Also, Dr. Watson believed the applicant should undergo and X-ray of the lumbar spine/thoracic spine, and cervical…

    • 960 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    Anterior Fusion

    • 515 Words
    • 3 Pages

    The central canal is patent. Multi-level mild to moderate neural foraminal narrowing is noted. EMG and nerve conduction study performed on 12/31/09 revealed no evidence of a left or right sided cervical radiculopathy. Based on the visit note dated 12/21/15, the patient complains of severe neck pain and upper extremity…

    • 515 Words
    • 3 Pages
    Improved Essays
  • Decent Essays

    Analytical Summary

    • 621 Words
    • 3 Pages

    Per the AME report dated 03/17/16, it was noted that should all conservative measures fail to relieve symptoms, further surgical consideration would be appropriate and would consist of a lumbar fusion. Consideration of an…

    • 621 Words
    • 3 Pages
    Decent Essays
  • Improved Essays

    Neck Pain Case Studies

    • 715 Words
    • 3 Pages

    This is a 45-year-old male with a 2-20-2015 date of injury. A specific mechanism of injury has not been described. DIAGNOSIS: Sprain of joints and ligaments of unspecified parts of neck, initial encounter 01/11/16 Progress Report describes that 15 minutes were spent in review of the results from the urinary drug screen, which was administered at the previous visit and deciding whether any modifications are appropriate to the treatment regimen. The pain is better and down to a 3/10. The neck pain remained mild.…

    • 715 Words
    • 3 Pages
    Improved Essays
  • Decent Essays

    DOI: 4/8/2011. Patient is a 63-year-old male route sales representative who sustained injury when he was taking bread rack off the left gate and he ended up falling off the truck and the rack fell on him. Per OMNI entry, IW is status post left knee surgery on 09/20/11 and right knee surgery on 02/26/16. Based on the progress report dated 09/21/16 by Dr. Pelton, the patient complains of persistent pain in neck which he rates at 6/10, it is constant and radiates to the shoulders and pain in the lower back at 7/10, it is constant and radiates down to both legs.…

    • 454 Words
    • 2 Pages
    Decent Essays
  • Improved Essays

    Low Back Pain

    • 708 Words
    • 3 Pages

    On 03/02/2017, the claimant presented with neck and thoracic spine pain rated at 7/10. She presented with some improvement. The plan of care included continued therapy to further increase the range of motion and spinal mobility. The Physical Therapy Note dated 03/06/2017, stated that the claimant felt sick after her last physical therapy session.…

    • 708 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    Medical Case Summary

    • 763 Words
    • 4 Pages

    The evidence in file shows the claimant has a history of chronic lumbar pain. She is mildly obese with a body mass index as high as 33. X-rays of the lumbar spine (LS) taken 7/9/13 show multilevel degenerative changes with spurring and mild anterolisthesis of L4-L5. Degenerative joint disease in the left hip was also noted. The LS MRI taken 3/25/16 shows multilevel degenerative changes.…

    • 763 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    Essay On Holistic Pain

    • 507 Words
    • 3 Pages

    Disc problems including sciatica pain, degenerative disc disease and disc prolapse are the serious health aliments that can produce bothersome symptoms. Spinal discs act as a cushion between the back bones and are very susceptible to injury or disease, causing severe pain in the back and legs. These problems greatly affect aging individuals because of wear and tear in the spine disc cartilage, causing the loss of normal function or structure and decrease quality of life. Proper pain management for disc problems is decisive to deal with this painful health ailment and prevent any serious outcome. Symptoms of Disc Problems…

    • 507 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    Spinal Cord Injury is a major problem that effects approximately 282,000 people in the U.S. and estimated 17,000 new SCI cases each year (“National Spinal Cord Injury Statistical Center,” 2016, p.1). The leading cause of spinal cord injury (SCI) are car accidents (29.3%), followed by falls (22%), gunshot wounds (16.9%), and sport injuries (8%) primarily accounting with males (Vallines, 2016). Leading that males have an accounting primarily with car accidents, that what happened to a male name Alex A. Alex A. a 22-year-old male had a car accident that caused a fracture in his vertebra. Immediately the patient was taken to the emergency room and was evaluated with a SCI. The car accident caused Alex to have no movement or sensory function below C2, but was only able to move his eyes and mouth.…

    • 942 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    Patient Injury Paper

    • 473 Words
    • 2 Pages

    He complains of on and off lower back pain, on and off right knee pain with some improvement and right ankle pain and occasional swelling upon prolonged standing and walking. Patient has difficulty with bending, prolonged standing and walking. On examination of the lumbar spine, flexion and extension is restricted by 10/10 degrees.…

    • 473 Words
    • 2 Pages
    Improved Essays