Back Pain Case Study

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An emergency department note dated 11/02/2017 indicated that the claimant presented with a low back pain and right hip pain. His back pain started a month ago and had been worse the past 2 weeks. He stated that pain is aggravated by sitting and slightly relieved by standing. His BMI was 31.92. A lumbar spine x-ray was ordered and medications were provided.

Three-view lumbosacral spine survey dated 11/02/2017 was unremarkable. There was no evidence of fracture, disc space narrowing, or scoliosis.

A visit note from Masahisa Amano, MD (Family Medicine), dated 11/03/2017, indicated that the claimant presented for a post ER follow-up visit with a sharp pain in the back radiating down to his right hip/leg. He stated that Ibuprofen and Cyclobenzaprine provided minimal relief. His blood pressure was 132/79. He was diagnosed with a back pain and abnormal liver function tests. A repeat of lab tests was recommended. …show more content…

Amano, dated 11/10/2017, indicated that the claimant reported that back pain was improving with medication. Ultrasound dated 06/10/2017 revealed a fatty liver with 2 mm gallbladder polyp. Previous laboratory results dated 05/31/2017 showed GGT at 349, AST at 53, and ALT at 86. A repeat of laboratory tests dated 11/04/2017 showed an elevated GGT at 193 with normal levels of AST at 28 and ALT at 31. His BMI was 33.79. He was diagnosed with a fatty liver disease. A referral to contemporary PT was

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