DOI: 9/9/2015. Patient is a 63-year-old male salesperson who sustained injury when he slipped on the showroom floor. As per OMNI entry, patient was diagnosed with left upper arm shoulder sprain. MRI of the cervical spine without contrast done on 3/4/2016 revealed disc bulges and disc osteophyte complexes along the cervical spine with shallow posterior disc herniations at C4-C5, C5-C6 and C6-C7 level; these changes cause mild spinal canal narrowing. The changes at C4-C5 and C6-C7 slightly flatten the ventral surface of the cord.
Lordosis is decreased. Lasegue’s is equivocal, bilaterally. There is positive straight leg raise at 70 degrees, bilaterally, eliciting pain in L5-S1 dermatome distribution. Physical exam reveals tightness and spasm of the paraspinal musculature, bilaterally. There is hypoesthesia at the anterolateral aspect of foot and ankle of an incomplete nature noted at L5, and S1 dermatome level, bilaterally.
DOI: 1/25/2008. Patient is a 55-year-old male service technician who sustained a work-related injury when he slipped and fell while installing a tub. Urine drug screen dated 2/1/16 (no official result) revealed that the patient is consistent with the prescribed regimen. In a supplemental report on a pain management progress dated 6/20/16, the patient still has mild swelling and pain to be expected status post total left knee replacement. Diagnoses include hemarthrosis of knee or lower leg; hemarthrosis of left knee, lumbar facet arthropathy, bursitis of left shoulder, derangement of medial meniscus due to old tearing/injection of the left knee; and complete rupture of rotator cuff.
DOI: 7/22/2015. Patient is a 43-year-old male flagger who sustained injury to his right shoulder while moving cones on a trailer. As per OMNI entry, he was initially diagnosed with shoulder strain. He is status post right shoulder arthroscopic partial acromionectomy, resection of distal clavicle, resection of partial-thickness supraspinatus tendon tear, and intraarticular and acromial steroid Marcaine cocktail injections per operative report dated 7/11/16. Per the PT note dated 11/16/16, the patient has attended 43 visits for the right shoulder.
There is also tenderness to palpation bilaterally at paraspinal L5-S1. Straight leg raise is positive bilaterally, localizing to low back pain with ipsilateral leg pain. Sensation decreased over the bilateral L5 dermatomes, left greater than right. Assessment includes: lumbosacral disc disease with radiculopathy. Treatment plan includes request for bilateral L5-S1 transforaminal epidural steroid injections continue follow-up as directed.
Rotator Cuff Pain Health History: The patient is a middle age male with history of shoulder injuries. Specifically, he cites previous rotor cuff instability of the glenohumeral (G/H) joint. The patient is unfamiliar with the significance of the injury and the components of the rotator cuff requesting explanation of how the rotator cuff works. Presentation and Examination: Palpation and engaging the rotator cuff muscles helps isolate and identify which muscles are injured. The patient presents increased pain with lateral rotation of the shoulder.
A 36-year-old white female was referred to a university pain clinic for evaluation of pain in her jaw and face. Her problem had started eight months earlier as a result of an automobile accident during which she sustained a “whiplash” injury and subsequent neck pain and stiffness. She also suffered from tension headaches. She had been evaluated by doctors with several different specialties, and had undergone neck traction, which produced pain in the teeth, jaws, and TM joints. She was evaluated by a neurologist who ordered CT scans of the head and neck, as well as an EEG.
DOI: 5/31/2016. Patient is a 44-year-old male warehouse operator who sustained injury to his right elbow when he struck his right upper extremity on a metal crate. Per OMNI, he was initially diagnosed with contusion of the right elbow. Per the progress report dated 07/20/16, a corticosteroid injection was provided into the right elbow. Based on the progress report dated 08/22/16, the patient continues with on and off, achy and sharp stabbing right elbow pain and stabbing pain in the right wrist.
Sometimes the pain that may spread to the lower back and the legs. • Tenderness, weakness, or stiffness in the buttocks. • Pain that gets worse during physical activity. • Bruising. DIAGNOSIS This condition is diagnosed based on your symptoms, a physical examination, and your medical history.
Due to this progressive muscle weakness, often the patients become bound to the wheelchair at an early age. Usually scoliosis surgery and/ or physical therapeutic measures such as physiotherapy or glucocorticoids are recommended for slowing disease progression and to offer symptomatic relief. However, due to the unavailability of disease-modifying treatment,
DOI: 12/18/2014. The patient is a 56-year old male route sales representative who sustained a work-related injury to his lower back due to slip/fall on black ice while walking from his truck. As per OMNI entry, he was initially diagnosed with lumbosacral sprain. MRI of the Lumbar Spine without Contrast dated 01/23/2015 showed lumbar spondylosis at L1-2 though L5-S1 discs. At L4-5, there is a 4-mm posterior osteophyte-disc complex more prominent laterally and on the left side.
DOI: 5/22/2000. Patient is a 52-year-old female stitcher operator who sustained injury while she was pushing load onto a stitcher when she strained her right shoulder, wrist elbow, and neck. She underwent exploration of cervical fusion at C5-T7 with anterior cervical discectomy with fusion at C3-C5 on 12/13/11 and implantation of new implantable pulse generator (IPG) and spinal cord stimulator unit on 09/17/14. Based on the latest medical report dated 01/29/16, the IW presents for follow up of neck and shoulder pain. IW complains of increased pain and swelling in her neck, supraclavicular, clavicular and trapezius areas bilaterally, worse on the right.
DOI: 05/21/2015. Patient is a 52-year-old male control operator who sustained an injury to his low back after lifting 42-pound rolls. Patient is diagnosed with lumbar isthmic spondylolisthesis, lumbar degenerative disc disease, lumbar foraminal stenosis, and lumbar radiculopathy. MRI of the lumbar spine dated 09/01/15 showed L5 to S1 pars defects with mild spondylolisthesis. There is a 4.5mm generalized disc bulging and redundancy of the disc annulus with impingement of existing L5 nerve roots at neural foraminal level, right greater than left.
The patient has been on Ultram, chronically. The patient had a primary total knee arthroplasty in 1993, a first revision in 1998, and a third revision in 2001. The patient stated that his pain has been gradually worsening for a year to the point that he can no longer do his job. He cannot sit, stand, jog or jump. He not only has knee complaints but also problems in his lower back, bilateral feet and his lefts shoulder.
DOI: 09/26/2010. The patient is a 63-year-old male route sales representative who incurred a work-related injury to his left foot and ankle due to repetitive job duties. Based on the progress report dated 03/18/16, the patient presents for reevaluation of his left ankle. He underwent left ankle surgery on 10/15/13. His left ankle has been worse the past two months.