Pain Management Case Studies
DOI: 11/11/2011. Patient is a 52-year-old male nursing assistant who sustained an injury while he was repositioning a patient when he heard cracking sound and felt pain and burning in his low back. He is status post anterior retroperitoneal exposure of the L5-S1 space with mobilization of the bilateral iliac vein and artery on 10/02/12. Per OMNI, he was declared MMI on 09/18/13.
Based on the progress report dated 03/02/16, the patient reports increased pain for about a week. He rates the pain 5/10 with medications and 8/10 without. He is interested in some PT to help with the pain. The pain is in the low back and occasionally radiates to the left lower extremity. He uses tramadol for the severe pain and Flexeril for muscle spasms. He requests a Toradol injection for the pain flare up. He needs refills. A mandatory urine drug screen was requested, to be done prior to providing medications so as to minimize the potential for the abuse and diversion of controlled substances. …show more content…
Lumbar spine range of motion (ROM) is decreased for about 10%.
Diagnoses include Grade 1 spondylolisthesis L5-S1, left L5-S1 bulge and impingement on the L5 root and status post anterior lumbar discectomy and fusion (ALDF) 10/2/12.
Treatment plan includes PT x 4 weeks to decrease pain and increase strength and as it has been very helpful in the past.
Toradol intramuscular injection was provided due to moderate to severe pain which precludes normal function. A comprehensive qualitative urine drug screen was administered.
Per OMNI payment screen, the last PT session was in
Based on the progress report dated 03/02/16, the patient reports increased pain for about a week. He rates the pain 5/10 with medications and 8/10 without. He is interested in some PT to help with the pain. The pain is in the low back and occasionally radiates to the left lower extremity. He uses tramadol for the severe pain and Flexeril for muscle spasms. He requests a Toradol injection for the pain flare up. He needs refills. A mandatory urine drug screen was requested, to be done prior to providing medications so as to minimize the potential for the abuse and diversion of controlled substances. …show more content…
Lumbar spine range of motion (ROM) is decreased for about 10%.
Diagnoses include Grade 1 spondylolisthesis L5-S1, left L5-S1 bulge and impingement on the L5 root and status post anterior lumbar discectomy and fusion (ALDF) 10/2/12.
Treatment plan includes PT x 4 weeks to decrease pain and increase strength and as it has been very helpful in the past.
Toradol intramuscular injection was provided due to moderate to severe pain which precludes normal function. A comprehensive qualitative urine drug screen was administered.
Per OMNI payment screen, the last PT session was in