Iw Case Studies

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DOI: 1/16/2014. Patient is a 48-year-old female price checker who sustained injury while she was locking cabinet when the fixture and monitor fell off and hit her in the head. Patient had a head contusion. Per PT notes dated 03/13/14, the IW has attended 5 sessions for the neck. Based on progress report dated 05/23/14, the patient reports of continued dull aching pain and burning sensation into the cervical spine. She received 2 cc of lidocaine with no epinephrine in the bilateral trapezius, cervical rhomboid, and cervical paraspinal muscles on this visit. Based on progress report dated 07/10/15, the patient complains of unchanged, sharp, dull and aching pain in the cervical spine, which radiates to the bilateral upper extremities. Baseline is 6-7/10 pain. Rest and medications help alleviate the pain. Activities at home and work worsen the pain. Numbness, tingling, and burning sensation are reported with increased pain throughout the week. The patient is requesting medication refills and reports limitations with gripping, grasping, pushing, pulling, and lifting 10 pounds. Activities of daily living are limited due to pain, as…show more content…
Range of motion is limited with flexion and extension of 20 degrees limited by pain. Spurling test is positive. Sensation is diminished C5-C6 bilaterally. Diagnoses are cervical strain, bilateral C5-C6 cervical radiculopathy, and diminished sensation, C6 reflex bilaterally. The patient has completed physical therapy, time, rest, medications, chiropractic care, and acupuncture with no alleviation of the pain. Significant pathology on the MRI is noted with degenerative disk disease, neural foraminal stenosis and a nerve root impingement in the cervical spine. Treatment plan includes epidural at the bilateral C5-C6 level, continuation with home exercise program and medications and follow up in 2 weeks. She was given a prescription for Lidoderm

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