Qtr 1 Physician IRR 2017 MSK (Spine Surg) case study # 3

BCBSKC COMMERCIAL PPO -38 y/o F L5-S1 Decompression and Lumbar Spine Fusion, CPT 22633

S/S: Mod-severe LBP x 10 yrs. Sx worsening x 2 months and occurs persistently. LBP radiating to rt thigh and rt buttock. Pain is an ache, burning and numbness. Sx aggravated by bending, lifting, sitting, standing, being in one position for too long. Relieved by changing positions. Assoc. Sx include numbness in the legs and night pain.
FOV 9/22/16 LOV 11/1/16
PE: Ht: 68 in, Wt 228.6 Ibs, BMI 34.75. Exam: A/O. Has just a little hitch in her gait, but has decent strength. Can heel walk, toe walk, and deep knee bend. +SLR on anterior flexion. Has increased pain in her back and some down lt leg. Reflexes to knees are 2+ and symmetric. Ankles are slightly asymmetric with the rt being 2+ and lt 1+. Normal muscle strength.
Normal ROM, muscle strength, and stability in all extremities with no pain on inspection. Antalgic gait
Neuro Exam: No Hoffman; no clonus
Psychiatric: Oriented to time, place, person, and situation. Behaves appropriately for age, normal insight, normal judgment. Demonstrates appropriate mood and affect. No Waddell's testing noted.
Current Medications: Ibuprofen 200 mg tablet 1 tablet PRN Q6 hrs x duration unspec.
Smoking Hx: NEVER smoker.
TX: No PT noted. No Psychological testing noted.
Prior Imaging: 10/17/16: MRI L-Spine wo: DDD greatest at L5-S1. No evidence for high grade spinal or neural foraminal stenosis.
4 Views Lumbosacral /Spine, Flexion and Extension. Technique: An AU view of the lumbosacral spine was obtained, as well as lateral views in flexion, and extension. Findings; The vertebral bodies are aligned. There is to loss of vertebral body stature. There is mild loss of intervertebral disc ht at L5—S1. There is no abnormal movement identified. Impression: No significant findings.
Dx/ Reason for surgery:
Other intervertebral disc degeneration, lumbosacral region, Radiculopathy, lumbosacral region

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