Nursing Case Study Essay
nurse who had a back strain from holding down a 4-year old during an immunization shot. As per OMNI notes, the patient was initially diagnosed with low back strain. IW was deemed permanent and stationary on 09/24/13 with 7% whole person impairment rating. Future medical care includes office visits with an orthopedist, PT, acupuncture, medications, injections and diagnostic studies.
Patient underwent an L5-S 1 interlaminar epidural steroid injection per the operative report dated 06/05/13.
MRI of the lumbar spine dated 12/14/16 revealed early degenerative disc and facet changes, without significant canal or foraminal compromise. At L3-4 and L4-5 levels, there are degenerative disc changes with desiccation and loss of disc height. The disc is diffusely bulging. There are degenerative facet changes noted. There is a mild degree of canal …show more content…
Straight-leg-raising test on the right reproduces sharp pain in the sacroiliac pain, left reproduces back pain.
Quadriceps reflexes were 1-2+ and symmetrical.
Achilles reflexes were 0-1+ and symmetrical.
Of note, the right SI joint was examined under ultrasound and injected, which has been very helpful in the past for the patient. Under ultrasonic guidance, the bilateral SI joint was injected, which significantly reduced her pain up to 60-70%.
She ambulates with a slight antalgic gait.
The patient has been provided with appropriate medications to maintain her condition until her next follow-up visit.
The patient also could benefit from one singular epidural injection directed at L4-L5, where on the MRI scan, she is noted to have some lateral recess stenosis.
Requested verification from the provider’s office on the response from the previous Epidural Steroid Injection (ESI) on 06/05/13. ; however, no callback/report was received prior to the submission of this request to PA.
Current request is
Patient underwent an L5-S 1 interlaminar epidural steroid injection per the operative report dated 06/05/13.
MRI of the lumbar spine dated 12/14/16 revealed early degenerative disc and facet changes, without significant canal or foraminal compromise. At L3-4 and L4-5 levels, there are degenerative disc changes with desiccation and loss of disc height. The disc is diffusely bulging. There are degenerative facet changes noted. There is a mild degree of canal …show more content…
Straight-leg-raising test on the right reproduces sharp pain in the sacroiliac pain, left reproduces back pain.
Quadriceps reflexes were 1-2+ and symmetrical.
Achilles reflexes were 0-1+ and symmetrical.
Of note, the right SI joint was examined under ultrasound and injected, which has been very helpful in the past for the patient. Under ultrasonic guidance, the bilateral SI joint was injected, which significantly reduced her pain up to 60-70%.
She ambulates with a slight antalgic gait.
The patient has been provided with appropriate medications to maintain her condition until her next follow-up visit.
The patient also could benefit from one singular epidural injection directed at L4-L5, where on the MRI scan, she is noted to have some lateral recess stenosis.
Requested verification from the provider’s office on the response from the previous Epidural Steroid Injection (ESI) on 06/05/13. ; however, no callback/report was received prior to the submission of this request to PA.
Current request is