DOI: 05/02/2016. Patient is a 38-year-old female packer who sustained a low back injury after dumping a garbage bag full of foam. Per OMNI entry, she was initially diagnosed with low back strain.
Per the medical report dated 07/12/16, the patient presented for her 6/6 chiropractic visit. She will continue her home exercises.
Per the medical report dated 07/29/16, the patient presented for her 6/6 acupuncture visits.
MRI of the lumbar spine dated 08/22/16 revealed L5-S1 annular bulge eccentric to the right and moderate right and mild to moderate left foraminal stenosis, and mild narrowing of the right lateral recess. At L4-5, there is a mild to moderate left and mild right foraminal stenosis. There is a mild narrowing of the left lateral recess.
Per the medical report dated 08/29/16, the patient complained of right-sided low back pain radiating down …show more content…
Tenderness was noted in the quadratus lumborum and paraspinous region. Straight leg raise examination was positive on right side. Lumbar range of motion was decreased. Foot drop was absent. On extremity examination, tenderness was noted. Range of motion was decreased.
Patient was diagnosed with myofascial pain syndrome, lumbar disc displacement, lumbar radiculopathy and lumbar sprain/strain. Sample medications of Lyrica 50 mg was given to the patient.
Treatment plan includes further testing with EMG and nerve conduction study to further assess her injury as well as MRI of the lumbosacral spine if not yet done, trial of electro-acupuncture treatment and lumbar epidural steroid injection under fluoroscopic guidance.
Recommendation was made for use of back brace, as the patient reports she has a lot of back activities causing increased pain and discomfort.
Patient has been previously denied with 1 Lumbar Transforaminal Steroid Injection at the Right L4-L5 and L5-S1 Levels under Fluoroscopic Guidance on 09/07/16 (Review
Per the medical report dated 07/12/16, the patient presented for her 6/6 chiropractic visit. She will continue her home exercises.
Per the medical report dated 07/29/16, the patient presented for her 6/6 acupuncture visits.
MRI of the lumbar spine dated 08/22/16 revealed L5-S1 annular bulge eccentric to the right and moderate right and mild to moderate left foraminal stenosis, and mild narrowing of the right lateral recess. At L4-5, there is a mild to moderate left and mild right foraminal stenosis. There is a mild narrowing of the left lateral recess.
Per the medical report dated 08/29/16, the patient complained of right-sided low back pain radiating down …show more content…
Tenderness was noted in the quadratus lumborum and paraspinous region. Straight leg raise examination was positive on right side. Lumbar range of motion was decreased. Foot drop was absent. On extremity examination, tenderness was noted. Range of motion was decreased.
Patient was diagnosed with myofascial pain syndrome, lumbar disc displacement, lumbar radiculopathy and lumbar sprain/strain. Sample medications of Lyrica 50 mg was given to the patient.
Treatment plan includes further testing with EMG and nerve conduction study to further assess her injury as well as MRI of the lumbosacral spine if not yet done, trial of electro-acupuncture treatment and lumbar epidural steroid injection under fluoroscopic guidance.
Recommendation was made for use of back brace, as the patient reports she has a lot of back activities causing increased pain and discomfort.
Patient has been previously denied with 1 Lumbar Transforaminal Steroid Injection at the Right L4-L5 and L5-S1 Levels under Fluoroscopic Guidance on 09/07/16 (Review