DOI: 9/14/2016. Patient is a 70-year-old female registered nurse who sustained a work-related injury to her right knee, thoracic spine, and lumbar spine when she tripped over a computer cord and landed on her right knee. As per OMNI, the patient developed pain into her right low back and buttocks that travels down her right leg. Per OMNI entry, patient was diagnosed with L4-5 listhesis, L3-4 retrolisthesis with herniated nucleus pulposus (HNP) and lumbar strain.
MRI of the lumbar spine dated 10/27/16 revealed progressive degenerative disc disease with central canal stenosis at L4-5 and to lesser extent at L3-4, both progressed compared to the prior study of 07/03/14. In addition, there is neural foraminal stenosis, which is slightly progressed from before as well.
Per the …show more content…
She rates it 5-6/10 but it increases with activities.
She has subjective and objective symptoms of radiculopathy, an MRI with findings that correlate with her findings, and the pain is intolerable. She needs refills of her medications. The topical patches help her pain and allow her to function without narcotics. She needs PT to improve her strength and range of motion.
She is not working as there is no modified duty available.
On examination, there is positive lumbar tenderness. Lumbar spine range of motion is decreased about 30%. Muscle spasms are noted in the paraspinal musculature. Reflexes are decreased bilaterally. Strength and sensation are decreased bilaterally at L4 and L5. Straight-leg raise and bowstring are positive bilaterally.
Gait is antalgic. IW can heel and toe-walk bilaterally, but this is difficult.
Patient was diagnosed with lumbar strain and L4-5 listhesis, L3-4 retrolisthesis with HNP and sprain/strain at L3-4 and L4-5.
She was given a prescription for Naproxen 500 mg 1 tablet twice daily #90 and Lidocaine 5% 1 patch to be applied 12 hours on and off
MRI of the lumbar spine dated 10/27/16 revealed progressive degenerative disc disease with central canal stenosis at L4-5 and to lesser extent at L3-4, both progressed compared to the prior study of 07/03/14. In addition, there is neural foraminal stenosis, which is slightly progressed from before as well.
Per the …show more content…
She rates it 5-6/10 but it increases with activities.
She has subjective and objective symptoms of radiculopathy, an MRI with findings that correlate with her findings, and the pain is intolerable. She needs refills of her medications. The topical patches help her pain and allow her to function without narcotics. She needs PT to improve her strength and range of motion.
She is not working as there is no modified duty available.
On examination, there is positive lumbar tenderness. Lumbar spine range of motion is decreased about 30%. Muscle spasms are noted in the paraspinal musculature. Reflexes are decreased bilaterally. Strength and sensation are decreased bilaterally at L4 and L5. Straight-leg raise and bowstring are positive bilaterally.
Gait is antalgic. IW can heel and toe-walk bilaterally, but this is difficult.
Patient was diagnosed with lumbar strain and L4-5 listhesis, L3-4 retrolisthesis with HNP and sprain/strain at L3-4 and L4-5.
She was given a prescription for Naproxen 500 mg 1 tablet twice daily #90 and Lidocaine 5% 1 patch to be applied 12 hours on and off