Patient Injury

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Recommended: Rehabilitation process positive

DOI: 6/1/2014. Patient is a 44-year-old male dishwasher who sustained injuries to his right shoulder, back and both legs when he slipped and fell while detaching grill. Per OMNI, he was initially diagnosed with
Per operative reports, patient is status post lumbar ESI at L5-S1 on 05/26/15 and right L4, L5 and S1 selective nerve block on 04/07/15.
Based on the progress report dated 02/10/16, the patient presents for a follow-up evaluation. He was last seen on 06/03/15 when he presented after a lumbar ESI at L5-S1. At that time, the IW admitted his shooting pain to his right leg completely disappeared. He experienced pain across his lower back with radiation to buttocks and upper posterior thighs. He presented with osteogenic pain at this time. He continued to experience severe pain in his lower back, left more than the right side. Pain is increase with sitting, standing, trying to get up after prolonged sitting or walking stairs with radiation to both buttocks and upper posterior thighs. Pain continued to interfere with daily activities and …show more content…

Range of motion (ROM) is diminished on extension and side rotation with severe pain. There is minimal pain with flexion. Straight leg raise in the sitting position was 60 degrees on the right and 55-60 degrees on the left with lower back pain and tension in the hamstrings. Kemp’s test is positive at L3-4, L4-5 and L5-S1 levels. Impressions are resolved right lumbar radiculopathy at L5-S1 and continued bilateral lumbar posttraumatic facet syndrome at L3-4, L4-5 and L5-S1 levels. Plan is for a bilateral lumbar diagnostic medial branch block under fluoroscopy and light sedation at L3-4, L4-5 and L5-S1 levels. IW accepted this

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