Medical Case Study: Serial Sevens
DOI: 11/11/1998. Patient is 49-year-old male inventory clerk who sustained a work related injury when he was struck on the head by a descending forklift.
Per the medical report dated 02/22/13, the patient has had a CT scan of the cervical spine on 11/11/98 (no official report), which showed minor spurring to the left of midline at C6-7 level posteriorly without significant spinal stenosis.
Per the medical report dated 11/02/15, the patient admits radiation of neck pain to the upper extremities on both sides, accompanied by tingling and numbness. Pain is alleviated by water therapy. Methods tried to manage pain includes PT one month ago, ice, rest and medications. It was noted that she has had a cervical epidural steroid injection (ESI) in …show more content…
Patient has palilalia, which is quite deliberate. He was not able to do abstract part of the Serial Sevens, because he said that his eyes hurt when he reads anything. Patient complained of pain when moving his eyes and has severe photophobia.
Current medications include morphine sulfate, methocarbamol, gabapentin, lorazepam, docusate sodium, Fish Oil, Cymbalta, nitrostat, carvedilol, atorvastatin calcium and clopidogrel.
Of note, MRI of the cervical spine obtained on 08/29/16 (no official report) demonstrated disc herniations at the C5-6 and C6-7 levels causing moderate cord compression and left foraminal stenosis
IW was diagnosed with cervical herniated disc.
As the IW has failed to improve with conservative treatment, he would benefit from surgical intervention.
Recommendation was made for C5-7 anterior cervical discectomy with interbody arthrodesis and plating. He wishes to proceed.
Requested from the provider’s office copies of PT notes, Epidural Steroid Injection (ESI) procedure reports, MRI/CT/Xray reports and psychological evaluation report; however, no callback/report was received prior to the submission of this request to PA.
Current request is for 1 C5-C7 Anterior Cervical Discectomy and Fusion between 9/14/2016 and
Per the medical report dated 02/22/13, the patient has had a CT scan of the cervical spine on 11/11/98 (no official report), which showed minor spurring to the left of midline at C6-7 level posteriorly without significant spinal stenosis.
Per the medical report dated 11/02/15, the patient admits radiation of neck pain to the upper extremities on both sides, accompanied by tingling and numbness. Pain is alleviated by water therapy. Methods tried to manage pain includes PT one month ago, ice, rest and medications. It was noted that she has had a cervical epidural steroid injection (ESI) in …show more content…
Patient has palilalia, which is quite deliberate. He was not able to do abstract part of the Serial Sevens, because he said that his eyes hurt when he reads anything. Patient complained of pain when moving his eyes and has severe photophobia.
Current medications include morphine sulfate, methocarbamol, gabapentin, lorazepam, docusate sodium, Fish Oil, Cymbalta, nitrostat, carvedilol, atorvastatin calcium and clopidogrel.
Of note, MRI of the cervical spine obtained on 08/29/16 (no official report) demonstrated disc herniations at the C5-6 and C6-7 levels causing moderate cord compression and left foraminal stenosis
IW was diagnosed with cervical herniated disc.
As the IW has failed to improve with conservative treatment, he would benefit from surgical intervention.
Recommendation was made for C5-7 anterior cervical discectomy with interbody arthrodesis and plating. He wishes to proceed.
Requested from the provider’s office copies of PT notes, Epidural Steroid Injection (ESI) procedure reports, MRI/CT/Xray reports and psychological evaluation report; however, no callback/report was received prior to the submission of this request to PA.
Current request is for 1 C5-C7 Anterior Cervical Discectomy and Fusion between 9/14/2016 and