4th Qtr 2016 Physician RBM (Spine) Case Study#6
43 yof-MRI L-spine wo (72148)
CG/HLTHSPNG MD MCR HMO
Per Web, ACDS, Clinical notes/ IM R/t Radiating LBP to buttocks that started after pulling a canoe from the ocean. Duration x 3 weeks prior to 9/14/16 ov. Symptoms unchanged. Exacerbated by movement. Decreased activity and bilat calf cramps x 2 days. No weakness, incontinence. Reason: Evaluate lumbar radiculopathy
FOV: 9/14/16 LOV: 10/20/16
PE: L spine: normal gait. Normal ROM, strength, sensory. Normal ROM. Tender L lumbar.
PMH: No hx of Ca or surg. (+)pulling injury
TX: 9/14/16-10/20/16 ( 5 weeks) Soma, Celebrex, Medrol dose pack.
Prior Imaging: Xray L spine ordered 9/14/16. No report included
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