Case Study: A 49-Year-Old Patient
DOI: 3/1/2016. Patient is a 49-year-old male electrician who sustained a work-related injury to his back while he was bending over to pick an item up in the gang box. As per OMNI entry, he was initially diagnosed with left-sided low back pain with sciatica and constipation.
MRI of the lumbar spine without contrast dated 06/22/2016 showed disc protrusion with annular fissure at L5-S1, which can be a source of pain.
Per physical therapy notes dated 06/30/2016, the patient has attended a total of 33 treatment sessions following his evaluation of the lumbar disc.
Patient is status post lumbar interlaminal Epidural Steroid Injection (ESI) at left L5-S1 per the procedure report dated 09/20/16.
Based on the medical report dated 09/28/16, the patient had a lumbar epidural steroid injection with 0% relief status post procedure.
Based on the medical report dated 11/07/16 by Dr. Cenac, the patient complains of pain …show more content…
On examination of the lumbosacral spine, there is decreased range of motion. Sensation is decreased in the left S1 nerve distribution.
Straight leg raise is positive on the left. Of note, X-rays obtained on this date showed mild degenerative changes at L5-S1.
Assessments include chronic midline low back pain without sciatica and lumbar disc displacement.
If he does not want to proceed with second and third injection injections, then a left sided L5-S1 microdiscectomy can be accomplished.
He would like to proceed with this. He will remain off work. He will need a lumbar brace for mobilization and stabilization pre and post-surgery if the microdiscectomy is accomplished.
He was given a prescription for Zanaflex, Neurontin and Norco.
Current request is for 1 Left L5-S1 Microdiscectomy between 11/14/2016 and 1/13/2017; 1 Surgeon between 11/14/2016 and 1/13/2017; 1 Assistant between 11/14/2016 and 1/13/2017; 1 Lumbar Corset between 11/14/2016 and 1/13/2017.
This is 1 out of 2
MRI of the lumbar spine without contrast dated 06/22/2016 showed disc protrusion with annular fissure at L5-S1, which can be a source of pain.
Per physical therapy notes dated 06/30/2016, the patient has attended a total of 33 treatment sessions following his evaluation of the lumbar disc.
Patient is status post lumbar interlaminal Epidural Steroid Injection (ESI) at left L5-S1 per the procedure report dated 09/20/16.
Based on the medical report dated 09/28/16, the patient had a lumbar epidural steroid injection with 0% relief status post procedure.
Based on the medical report dated 11/07/16 by Dr. Cenac, the patient complains of pain …show more content…
On examination of the lumbosacral spine, there is decreased range of motion. Sensation is decreased in the left S1 nerve distribution.
Straight leg raise is positive on the left. Of note, X-rays obtained on this date showed mild degenerative changes at L5-S1.
Assessments include chronic midline low back pain without sciatica and lumbar disc displacement.
If he does not want to proceed with second and third injection injections, then a left sided L5-S1 microdiscectomy can be accomplished.
He would like to proceed with this. He will remain off work. He will need a lumbar brace for mobilization and stabilization pre and post-surgery if the microdiscectomy is accomplished.
He was given a prescription for Zanaflex, Neurontin and Norco.
Current request is for 1 Left L5-S1 Microdiscectomy between 11/14/2016 and 1/13/2017; 1 Surgeon between 11/14/2016 and 1/13/2017; 1 Assistant between 11/14/2016 and 1/13/2017; 1 Lumbar Corset between 11/14/2016 and 1/13/2017.
This is 1 out of 2