S/HPI- 58 y/o, retired, WM, accompanied by his wife, c/o chronic LBP x 20 years. States he has been seeing an MD for past 2 years, and told only option was to have back surgery. He is taking Vicodin, but states usually little relief and does not want to become addicted. States he has received 3 cortisone injections within.past 3 months with no relief. States he has three lumbar disc protrusions L-2, L-3 andns, one thoracic disc “displaced” and cervical stenosis. States has difficulty bending forward and moving “freely” from.side to side. Patient states his pain has made it difficult to perform any daily tasks and c/o having difficulty getting in and out of his truck. States he’s always in need of his wife’s assistant. Has plans to move tons of gravel to his yard, but cannot lift or move wheelbarrow. Cannot climb up or down a ladder to work on roof or clean gutters. States depends on wife. Pain Scale 8/10Personal Medical History: MVA 20 years ago. Treated at hospital and released. Given pain meds. No other significant medical historyFamily Medical: Both parents deceased. Father died at age of 72 from MI; Mother died from renal failure at 74 yrs2 Brothers: 56 and 54 and both are in good health1 sister: 50 with HTN and type 2 diabetes1 daughter: adopted SH: denies smoking, denies use of illicit drugs. ETOH: occasional glass of red wine with dinner. Has good relationship with siblings and daughter. Second marriage and has good relationship with wife. Spirituality: Attends local church every Sunday and helps with some church events. This patient left his PCP,and stopped by my office before going to his truck. He was unable to walk without assistance of his wife, and at a slow pace. I explained to patient that I could help alleviate his pain, but could not guarantee he would not have to have back surgery in the future. I told him, with 50/50 odds of becoming in a worse position, I did not recommend surgery. The odds are too high, I said. He agreed, and was given the same odds by his PCP. Since my day’s schedule was completely booked, I asked he return to my office during my lunch hour. He and his wife agreed. Upon return, his wife and I helped the patient walk to an exam room.O: Lumbar extension: Limited ROM Lumbar flexion: Limited ROM L/R lateral rotation: Limited ROM
Explained history, benefits and possible side effects of battlefield acupuncture. Explained that patient had to communicate the degree of pain attenuation after insertion of each needle. Starting number being 8/10. Stated after insertion of each needle, patient must move affected area 20-30 seconds and communicate the change, if any, in pain attenuation Stated the most significant decrease will be the ear the protocol will end and have 5 needle insertions. After insertion of 1st (L-CG) needle, patient stated he no longer felt pain, so protocol was completed on the L auricle.
Patient was able to get on exam table without assistance.
1st 15 minutes:
2nd 15 minutes
Total needle count in: 11
Total needle count out: 11
Patient tolerated treatment we not well with no adverse effects. Patient stated he was to do something he had not done in 13 years…take his wife out dancing
A: lumbar disc protrusion (per patient)
P: RTC 1 wk f/u
Consider stretching exercises
Chiropractor options for realignment
I keep up with this patient periodically, making a phone call about every 6 months to see how he is doing. He sees a chiropractor on occasion but states he’s had no pain and has not had to see an acupuncturist. Prior to my moving from Albuquerque, he was given a name of an acupuncturist in case he needed further pain management treatments.