Iw Injury
DOI: 8/15/2013. Patient is a 58-year-old female cleaner who sustained injury while she was cleaning and mopping the bathroom when she fell and hit her head/back. Per OMNI, she was diagnosed with cervical and lumbar radiculopathy, cervical herniations at C5-7, and lumbar herniation at L3-4. She underwent an anterior cervical diskectomy and fusion at C5-6 and C6-7 on 04/03/14 and lumbar laminectomy at L4-5 on 09/10/15.
Based on the medical report dated 01/19/16 by Dr. Haftel, the IW presents with continued complaint of neck and low back pain. IW reports constant lower back pain to be aching and sharp, with radiation down the bilateral lower extremity with intermittent numbness and tingling in the front of the leg including bilateral feet and …show more content…
IW reports constant neck pain as aching with exacerbations and radiation to bilateral shoulders/upper extremities. IW notes intermittent numbness and tingling to bilateral hands/fingers. IW reports major weakness in the upper extremities, not being able to grasp items and involuntarily drop items. IW reports being able to tolerate right wrist pain. IW reports exacerbation of pain due to change in weather. IW complains of headaches with dizziness and nausea. She attempts to avoid any exacerbating activities. The IW has tried pain medications and therapy which helps some. Her sleep quality is poor secondary to pain. She has a history of epidural injections with no change. She has been doing PT 3 days a week since her last visit with some improvement of symptoms. On examination of the cervical spine, bilateral paracervical and trapezius tenderness is noted. Bilateral palpable spasm is noted. Range of motion (ROM) shows flexion of 35 degrees, extension of 20 degrees, and bilateral rotation to 55 degrees, all with pain. On examination of the lumbar spine, bilateral paralumbar tenderness is noted with palpable spasm. Sacroiliac joint tenderness is noted, right greater than the left. ROM demonstrates flexion of 45 degrees and extension of 0 degrees, all with pain. Straight leg raise is positive bilaterally. Sensory
Based on the medical report dated 01/19/16 by Dr. Haftel, the IW presents with continued complaint of neck and low back pain. IW reports constant lower back pain to be aching and sharp, with radiation down the bilateral lower extremity with intermittent numbness and tingling in the front of the leg including bilateral feet and …show more content…
IW reports constant neck pain as aching with exacerbations and radiation to bilateral shoulders/upper extremities. IW notes intermittent numbness and tingling to bilateral hands/fingers. IW reports major weakness in the upper extremities, not being able to grasp items and involuntarily drop items. IW reports being able to tolerate right wrist pain. IW reports exacerbation of pain due to change in weather. IW complains of headaches with dizziness and nausea. She attempts to avoid any exacerbating activities. The IW has tried pain medications and therapy which helps some. Her sleep quality is poor secondary to pain. She has a history of epidural injections with no change. She has been doing PT 3 days a week since her last visit with some improvement of symptoms. On examination of the cervical spine, bilateral paracervical and trapezius tenderness is noted. Bilateral palpable spasm is noted. Range of motion (ROM) shows flexion of 35 degrees, extension of 20 degrees, and bilateral rotation to 55 degrees, all with pain. On examination of the lumbar spine, bilateral paralumbar tenderness is noted with palpable spasm. Sacroiliac joint tenderness is noted, right greater than the left. ROM demonstrates flexion of 45 degrees and extension of 0 degrees, all with pain. Straight leg raise is positive bilaterally. Sensory