Patient Case Summary
DOI: 3/16/2005. Patient is a 55-year-old female flight attendant who strained her back and left leg during a recurrent training. Per OMNI, she was initially diagnose d with lumbar sprain, lumbago and low back pain. Treatment includes electrical stimulation unit and PT.
Per the PT note dated 10/11/16, the patient reported continued symptoms, but she is working on managing her pain. She was assessed to have improved core stability.
Based on the progress report dated 10/27/16 by Dr. Waldman, the patient presents for reevaluation a little over 2 months since the last visit. She reports increased stiffness in her back and pain in the range of 7/10. It is aggravated by walking and sitting for long periods of time. Her hip and thigh pain is about …show more content…
the same. Interestingly, she has some significant anterior thigh pain on the right that is inexplicable based on her studies. She has avoided taking the gabapentin, which has been suggested for her sacroiliac radiculopathy. She is having difficulty sleeping at night. She is also requesting a lumbar support that she can wear at work.
On examination, the patient appears to be in some chronic discomfort, but can move about independently. She walks with a cautious gait, but can walk on her heels and toes with no gross weakness. She has decreased mobility of the back with forward flexion to within 11 inches of fingertips toes of extension, 10 degrees of lateral bend and 35 degrees of rotation in each direction.
She has positive straight leg raising on the left to her lower back. Reflexes are absent at the left ankle.
In the prone position, she has some slight pain on femoral stretch testing, bilaterally. She has a well-healed scar on the lower back with no increased warmth, swelling or point tenderness. She has slight irritability in the left hip.
Review of systems is positive for back/leg pain and easy bruising.
Current medications include lisinopril, liothyronine, Naprosyn, Neurontin and tizanidine.
Impressions include chronic back pain and sciatica status post micro discectomy of left L5-Sl with recurrent disc herniation, left groin and thigh pain associated with osteoarthritis of the left hip and right anterior thigh pain of undetermined etiology.
The patient was encouraged to increase her stretching and core strengthening exercises, since she seems to be less flexible and having more pain.
She was provided with prescription for additional physical therapy and for tizanidine to help her sleep at night.
She was encouraged to try the gabapentin for the radicular symptoms but not to start both at the same time. She will be seen back in 6 weeks for reevaluation. She may continue working.
Per OMNI payment screen, the patient has attended approximately 26 PT sessions from 01/29/15through
10/17/16.
Current request is for 8 Physical Therapy Visits for the Low Back between 11/3/2016 and 1/2/2017.
This is
Per the PT note dated 10/11/16, the patient reported continued symptoms, but she is working on managing her pain. She was assessed to have improved core stability.
Based on the progress report dated 10/27/16 by Dr. Waldman, the patient presents for reevaluation a little over 2 months since the last visit. She reports increased stiffness in her back and pain in the range of 7/10. It is aggravated by walking and sitting for long periods of time. Her hip and thigh pain is about …show more content…
the same. Interestingly, she has some significant anterior thigh pain on the right that is inexplicable based on her studies. She has avoided taking the gabapentin, which has been suggested for her sacroiliac radiculopathy. She is having difficulty sleeping at night. She is also requesting a lumbar support that she can wear at work.
On examination, the patient appears to be in some chronic discomfort, but can move about independently. She walks with a cautious gait, but can walk on her heels and toes with no gross weakness. She has decreased mobility of the back with forward flexion to within 11 inches of fingertips toes of extension, 10 degrees of lateral bend and 35 degrees of rotation in each direction.
She has positive straight leg raising on the left to her lower back. Reflexes are absent at the left ankle.
In the prone position, she has some slight pain on femoral stretch testing, bilaterally. She has a well-healed scar on the lower back with no increased warmth, swelling or point tenderness. She has slight irritability in the left hip.
Review of systems is positive for back/leg pain and easy bruising.
Current medications include lisinopril, liothyronine, Naprosyn, Neurontin and tizanidine.
Impressions include chronic back pain and sciatica status post micro discectomy of left L5-Sl with recurrent disc herniation, left groin and thigh pain associated with osteoarthritis of the left hip and right anterior thigh pain of undetermined etiology.
The patient was encouraged to increase her stretching and core strengthening exercises, since she seems to be less flexible and having more pain.
She was provided with prescription for additional physical therapy and for tizanidine to help her sleep at night.
She was encouraged to try the gabapentin for the radicular symptoms but not to start both at the same time. She will be seen back in 6 weeks for reevaluation. She may continue working.
Per OMNI payment screen, the patient has attended approximately 26 PT sessions from 01/29/15through
10/17/16.
Current request is for 8 Physical Therapy Visits for the Low Back between 11/3/2016 and 1/2/2017.
This is