Case Study On Lumbosacral Spine
On 8/15/16 I met Ms. Craton at the office of Dr. Tyler PCP. Ms. Craton arrived alone. She was able to sit and stand without difficulty. She is alert and oriented. Ms. Craton had a file folder with information for Hartford and Progress insurance. She is very cooperative agreeing to work with a nurse case manager and provide information.
MEDICAL FACTORS
Ms. Craton was driving on I-69 when a car weaving in and out of traffic caused a 4 car pileup. She reports she got out of her car and was standing at the side of the road. She bent over to pick up something and felt a pop in her back. She immediately went over to her PCP Dr. Tyler’s office. She was sent for an x-ray and a MRI of her lumbar spine. She tried physical therapy which increased her …show more content…
Conclusion: stable mild degenerative change in the lower lumbar, no dynamic instability.
MRI of the Cervical spine done on 5/9/16: Comparison cervical spine MRI without contrast of 9/5/13. Conclusion: Stable appearance of the cervical spine with several small central disc protrusions with minor mass effect on the ventral cervical cord without cord signal change. No significant foraminal stenosis. Chronic maxillary and sphenoid sinusitis.
MRI of the lumbar spine done on 5/9/16: Conclusion: shallow broad base disc protrusion L4-5 without clearly evident abutment of the traversing right L5 nerve roots. Slightly eccentric to the right L5S1 disc protrusion possibly abuts the traversing right S1 nerve root. Low grade facet arthropathy.
CURRENT STATUS Ms. Craton reports she has low back, right buttocks and right leg pain. She also said she will have cervical pain and shooting down the right arm occasionally. She said she cannot sit for more than 30 minutes before she needs to get up and move around. She reports her sleep is also disrupted. She is unable to mow her lawn. She said her pain is a 7 and at night will increase to a 12. Ms. Craton lives with her fiancé who had a recent major heart attack. Ms. Craton said she was not able to tolerate physical …show more content…
Craton said she wants to get better and get back to work.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as medical case manager and Ms. Craton verbalized understanding. She read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
Ms. Craton denied any legal representation.
IMPRESSIONS
Ms. Craton is overweight and has a sedentary lifestyle. She reports that her overall health is good. She denied any prior lumbar or cervical issues but the Cervical spine MRI report showed a prior test in 2013. She is very motivated to return to work. The Official Disability Guidelines for Lumbar spine Intevertebral Disc Disorder with mylopathy is 63 to 227 days. Epidural injections are pending. I would expect additional physical therapy to be done. The length of disability for a Whip lash is 25 to 412 days. Her pain to the cervical spine is intermittent.
PLAN/ RECOMMENDATIONS 1. Contact Ms. Craton for updates on her medical status.
2. Attend appointment with Dr. Tyler 2 weeks after the epidural injection is done. Obtain an updated work status, treatment option and projections for MMI.
3. Attend appointment with Dr. Morrison Nuclear Medicine when made to obtain treatment
MEDICAL FACTORS
Ms. Craton was driving on I-69 when a car weaving in and out of traffic caused a 4 car pileup. She reports she got out of her car and was standing at the side of the road. She bent over to pick up something and felt a pop in her back. She immediately went over to her PCP Dr. Tyler’s office. She was sent for an x-ray and a MRI of her lumbar spine. She tried physical therapy which increased her …show more content…
Conclusion: stable mild degenerative change in the lower lumbar, no dynamic instability.
MRI of the Cervical spine done on 5/9/16: Comparison cervical spine MRI without contrast of 9/5/13. Conclusion: Stable appearance of the cervical spine with several small central disc protrusions with minor mass effect on the ventral cervical cord without cord signal change. No significant foraminal stenosis. Chronic maxillary and sphenoid sinusitis.
MRI of the lumbar spine done on 5/9/16: Conclusion: shallow broad base disc protrusion L4-5 without clearly evident abutment of the traversing right L5 nerve roots. Slightly eccentric to the right L5S1 disc protrusion possibly abuts the traversing right S1 nerve root. Low grade facet arthropathy.
CURRENT STATUS Ms. Craton reports she has low back, right buttocks and right leg pain. She also said she will have cervical pain and shooting down the right arm occasionally. She said she cannot sit for more than 30 minutes before she needs to get up and move around. She reports her sleep is also disrupted. She is unable to mow her lawn. She said her pain is a 7 and at night will increase to a 12. Ms. Craton lives with her fiancé who had a recent major heart attack. Ms. Craton said she was not able to tolerate physical …show more content…
Craton said she wants to get better and get back to work.
CONSENT/EXPLANATION OF CASE MANAGEMENT
I explained my role as medical case manager and Ms. Craton verbalized understanding. She read and willingly signed the Authorization for Release of Medical Information form.
ATTORNEY
Ms. Craton denied any legal representation.
IMPRESSIONS
Ms. Craton is overweight and has a sedentary lifestyle. She reports that her overall health is good. She denied any prior lumbar or cervical issues but the Cervical spine MRI report showed a prior test in 2013. She is very motivated to return to work. The Official Disability Guidelines for Lumbar spine Intevertebral Disc Disorder with mylopathy is 63 to 227 days. Epidural injections are pending. I would expect additional physical therapy to be done. The length of disability for a Whip lash is 25 to 412 days. Her pain to the cervical spine is intermittent.
PLAN/ RECOMMENDATIONS 1. Contact Ms. Craton for updates on her medical status.
2. Attend appointment with Dr. Tyler 2 weeks after the epidural injection is done. Obtain an updated work status, treatment option and projections for MMI.
3. Attend appointment with Dr. Morrison Nuclear Medicine when made to obtain treatment