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Lumbar Case Summary

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DOI: 6/28/2016. Patient is a 29-year old female cook who sustained a work related injury to her back while unloading supplies. The patient is subsequently diagnosed with sprain of ligaments of lumbar spine, initial encounter. Per RFA dated 7/7/16, the request is an initial 3 visits per week for 2 weeks. As per medical report dated 7/7/16, patient complains of pain at the lumbar area. The patient describes the symptoms as sharp which is moderately severe. She reports having symptoms for 11days. The frequency is constant. The symptoms are exacerbated by motion. The symptoms are lessened by rest. Musculoskeletal examination revealed that there is tenderness of the thoracolumbar spine and paravertebral musculature at the lumbosacral junction. Range of motion of the back is restricted. …show more content…
Neurologic examination revealed that the straight leg raising test is positive; left, positive at 40 degrees; and right, positive at 60 degrees. Dispensed medication include acetaminophen, cyclobenzaprine, and etodolac. As per treatment plan narrative, it was noted that the expected maximum medical improvement (MMI) is on 8/31/16. Narcotics were not prescribed. Lumbar sprain consistent with mechanism of injury. Xrays done were negative. Plan is to request for chiropractic therapy to decrease pain and spasm. Etodolac and Tylenol are given for pain and inflammation. Flexeril is given for muscle spasm. Hot/cold packs are also given to be used in an alternating manner to reduce pain and discomfort. It was noted that the patient can return to work with restrictions as of 7/8/16. Restrictions include no overhead work, limited lifting, pulling, and pushing up to 5

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