DOI: 2/15/2012. Patient is a 60-year-old female registered nurse who sustained a work-related injury when she tripped and fell, striking her right hip. Per OMNI, she was initially diagnosed with 3 mm lumbar disc protrusion at L2-3, anterolisthesis at L4, right hip fracture, and status post open reduction and internal fixation on 03/03/12.
According to the AME report dated 11/07/13, the patient’s condition can be classified as permanent and stationary from an orthopedic standpoint.
Per the medical report dated 08/19/14, the patient has signs and symptoms of lumbar radiculitis, and has failed conservative treatment including anti-inflammatories, muscle relaxers and PT without a long term amelioration of her discomfort.
According to the supplemental AME report dated 01/07/15, provision should be made for the patient to receive future conservative orthopedic care consisting of oral analgesics and anti-inflammatory medications on an as needed basis. The patient may also require short courses of physical therapy (2-3 times per week for 4-6 weeks) for acute exacerbations of symptomatology. If her symptoms were to continue beyond that time, she should be re-evaluated by an orthopedist. The option for further right hip surgery should be left open if her condition deteriorates. It is not felt that the patient will require any other surgical procedures. …show more content…
Valdez, the patient complains of ongoing pain to her low back, which radiates to her legs. Patient also reports poor sleep and Medrol was very helpful last night. Patient has decreased spasms lately.
On examination, there is decreased range of motion. Straight leg raise is positive.
Patient was diagnosed with lumbar radiculopathy.
She was given a refill prescription for Norco 10/325 mg, Soma 350 mg, Ultram 50 mg, Motrin 800 mg and Neurontin 800 mg.
Treatment plan includes aquatherapy evaluation and treatment and re-evaluation in 1
According to the AME report dated 11/07/13, the patient’s condition can be classified as permanent and stationary from an orthopedic standpoint.
Per the medical report dated 08/19/14, the patient has signs and symptoms of lumbar radiculitis, and has failed conservative treatment including anti-inflammatories, muscle relaxers and PT without a long term amelioration of her discomfort.
According to the supplemental AME report dated 01/07/15, provision should be made for the patient to receive future conservative orthopedic care consisting of oral analgesics and anti-inflammatory medications on an as needed basis. The patient may also require short courses of physical therapy (2-3 times per week for 4-6 weeks) for acute exacerbations of symptomatology. If her symptoms were to continue beyond that time, she should be re-evaluated by an orthopedist. The option for further right hip surgery should be left open if her condition deteriorates. It is not felt that the patient will require any other surgical procedures. …show more content…
Valdez, the patient complains of ongoing pain to her low back, which radiates to her legs. Patient also reports poor sleep and Medrol was very helpful last night. Patient has decreased spasms lately.
On examination, there is decreased range of motion. Straight leg raise is positive.
Patient was diagnosed with lumbar radiculopathy.
She was given a refill prescription for Norco 10/325 mg, Soma 350 mg, Ultram 50 mg, Motrin 800 mg and Neurontin 800 mg.
Treatment plan includes aquatherapy evaluation and treatment and re-evaluation in 1