Esi Case Study
S: TM has completed ESI X 19 visits. ESI is helping him. Last 2 weeks heat has been applied and it seems to be helping him. AT rest his back pain is 0/10 with movement, at work 4/10. TM reports no difficulty of ROM, but prolonged bending or sitting causes pain in his lower back. TM has a history of motorcycle accident and injury to lower back. He has been taking naproxen and acetaminophen he as ordered, but at times the medications help and at times medications doesn’t help. TM denies any tingling, numbness, or loss of movement in his lower extremities.
O: No abnormality noted on inspection of his lower back; Normal gait; full lumbar spine range of motion; CN II - CN XII grossly intact; normal reflexes, + 5 strengths to lower and upper extremities,
+3 pulses to right and left pedal.
P
1. Extend ESI X 2 weeks
2. Continue with
Naproxen 220 mg tab, 1 tab by mouth every 12 hours X 2 week
Acetaminophen 500 mg tab 1 tab by mouth every 6 hours as needed X 2 week
Disposition: Full Duty follows up after ESI has completed and as needed
O: No abnormality noted on inspection of his lower back; Normal gait; full lumbar spine range of motion; CN II - CN XII grossly intact; normal reflexes, + 5 strengths to lower and upper extremities,
+3 pulses to right and left pedal.
P
1. Extend ESI X 2 weeks
2. Continue with
Naproxen 220 mg tab, 1 tab by mouth every 12 hours X 2 week
Acetaminophen 500 mg tab 1 tab by mouth every 6 hours as needed X 2 week
Disposition: Full Duty follows up after ESI has completed and as needed