Spine and Pain Case Studies 1
Oliver Ghalambor, MD, DABA, FIPP, DABIPP, DABPM
57 year old female
Referred by Dr. Rios Chiropractor
Chief Complaint “Right Low Back and leg Pain”
Seen in consultation initially on 09/06/2017
Vitals: W 199lbs, H 65in, BMI 33.1, BP 151/89
Pulse 68, Pain 9/10 VAS
Past Medical History:
– Migraine/ Headaches
– High Cholesterol
Non-smoker, occasional drinker
Employment: Texas Dept of Health and Human Services eligibility worker
Transforaminal Epidural Steroid Injection
Case 2 Details
28 year Supervisor Auto body repair shop
Initial consultation 10/27/16
Found us by “Google search”
Chief Complaint “Low Back Pain”
Upon Exam he was unable to sit comfortably.
Rated the pain as 9/10.
Pain upon percussion of the low lumbar region.
Normal neurological exam.
Prescribed muscle relaxant (Flexeril) 10 mg po qhs and hydrocodone 7.5-325 mg po tid prn.
First Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 11/01/2016 > 30% Relief
Second Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 11/29/2016 > 50% Relief
Third Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 12/27/2016 > 70% Relie