4th Qtr 2016 Physician MSK (Spine) Case Study#5

38yof-Lumbar Arthrodesis 22633

BCBSKC COM PPO

S/S: Low back pain.
Onset: 10 years ago. severity level is moderate-severe. For 2 Months, the problem is worsening. It occurs persistently. Location of pain is lower back- Pain is radiated to the right thigh and right buttock. The patient describes the pain as an ache, burning and numbness- Symptoms are aggravated by bending, lifting, sitting, standing and Being in one position for too long. Symptoms are relieved by Changing positions. Associated symptoms include numbness in the legs and night pain.
PE: Height: 68 in, Weight 228.6 Ibs, BMI 34.75.
alert and oriented and has just a little hitch in her gait, but she has decent strength. She can heel walk, toe walk, and deep knee bend. She has a positive straight leg raise on anterior flexion. She has increased pain in her back and some down her left leg. Her reflexes to her knees are 2+ and symmetric. The ankles are slightly asymmetric with the right being 2+ and the left 1+.
Normal ROM/Strength x 4
SLR positive, no side specified.
deep palpate ci joint illicits pain.
A/O x 4. No Waddell's testing noted.
TX: Ibuprofen 200 mg tablet 1 tablet as needed every 6 hours. Exact duration unspecified. No PT
Non-Smoker
10/17/16: MRI L-Spine wo:
Degenerative disc disease greatest at L5-S1. There is no evidence for high grade spinal or neural foraminal stenosis.
Xray Lumbosacral /Spine, Flexion and Extension.
No significant findings

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