DOI: 3/18/2003. The patient is a 58-year old female cleaner who sustained a work-related injury when she lifted a trash can and shifted the wrong way. Per PT daily note dated 06/20/11, IW has attended 7 sessions.
IME dated 04/24/2014 revealed that the patient is at MMI. From an Orthopedic standpoint, the patient requires no further physical therapy, orthopedic treatment, or diagnostic testing.
Per the medical report dated 10/22/15, an MRI of the lumbar spine dated 10/17/15, demonstrates at L5/S1, there is a disc herniation with severe lateral recess stenosis and bilateral foraminal impingement. At L4/5, there is a broad based disc herniation with significant lateral recess stenosis. There is anterior thecal sac impingement. There is also bilateral …show more content…
The right back and leg pain has resolved. The patient states that, “I now have this pain, the same pain, on the right side.” Pain is described as shooting and tingling. It gets hot, burning and tingling. The left leg is worse than the back. There is a radicular distribution by history at the left lower extremity (LLE). Paresthesias are also noted at the LLE. Neurogenic claudication is noted. IW feels better with flexion. Exacerbating factors are waking, sitting, activities of daily living and recreation. Rest alleviates symptoms. IW would like to minimize medications. She has had poor relief with analgesics and refuses analgesics. She is unable to tolerate activities of daily living.
She is currently using a Lidoderm 5% patch.
On examination of the lumbar spine, spasm and tenderness is noted upon paravertebral palpation. Straight leg raise is noted at 60 degrees on the left. Left L5 hypoesthesia is noted. Range of motion is limited. Facet loading test is noted at the LLE.
IW was assessed to have lumbar osteoarthritis. She was given a prescription for Lidoderm and gabapentin. Treatment plan includes PT, follow-up visits and left L5-S1 ESI under
IME dated 04/24/2014 revealed that the patient is at MMI. From an Orthopedic standpoint, the patient requires no further physical therapy, orthopedic treatment, or diagnostic testing.
Per the medical report dated 10/22/15, an MRI of the lumbar spine dated 10/17/15, demonstrates at L5/S1, there is a disc herniation with severe lateral recess stenosis and bilateral foraminal impingement. At L4/5, there is a broad based disc herniation with significant lateral recess stenosis. There is anterior thecal sac impingement. There is also bilateral …show more content…
The right back and leg pain has resolved. The patient states that, “I now have this pain, the same pain, on the right side.” Pain is described as shooting and tingling. It gets hot, burning and tingling. The left leg is worse than the back. There is a radicular distribution by history at the left lower extremity (LLE). Paresthesias are also noted at the LLE. Neurogenic claudication is noted. IW feels better with flexion. Exacerbating factors are waking, sitting, activities of daily living and recreation. Rest alleviates symptoms. IW would like to minimize medications. She has had poor relief with analgesics and refuses analgesics. She is unable to tolerate activities of daily living.
She is currently using a Lidoderm 5% patch.
On examination of the lumbar spine, spasm and tenderness is noted upon paravertebral palpation. Straight leg raise is noted at 60 degrees on the left. Left L5 hypoesthesia is noted. Range of motion is limited. Facet loading test is noted at the LLE.
IW was assessed to have lumbar osteoarthritis. She was given a prescription for Lidoderm and gabapentin. Treatment plan includes PT, follow-up visits and left L5-S1 ESI under