Client has pain when extending the neck towards the sternum, lateral extension of the right side, and reduced range of motion in rotation of the neck towards the left side of the body. Patient explains that prior to her injury she could touch her chin to her sternum area, easily rotate her head from right to left and look over her shoulder. She complains of lack of sleep due to pain, headaches, problems with driving and inability to bend neck to read, eat, and engage in office/school work. Client loves to take long drives, put together puzzles, and play video
The MRI revealed a troublesome rotator cuff tear in Lt. Scalzo’s left shoulder. Since the condition required an immediate treatment, Dr. Tehrany recommended and promptly scheduled a shoulder surgery to repair the rotator cuff tear.
The symptoms can vary and the symptoms can worse on some days and not really noticeable on others. If the condition is serious, the pain may not go away and it may affect you in your everyday life. For example, it may stop you from sleeping through the night and could cause difficulties when trying to carry out daily tasks like climbing
On behalf of Cpt Wu 's, Major Blount reviewed have reviewed your MRI. MRI findings are the following: 1. Degenerative tear of the glenoid labrum. 2. Full-thickness tear of the anterior portion of the supraspinatus tendon. 3. Partial thickness articular surface tear of the remaining portion of the supraspinatus tendon and infraspinatus tendon and subscapularis tendinopathy. 4. Severe osteoarthritis of the glenohumeral and acromioclavicular joint.
DOI: 4/16/2012. Patient is a 29-year-old male technician who sustained injury when he was 25-feet up on a ladder when the ladder slid and he fell onto the pavement. He had an open reduction internal fixation (ORIF x 2) for a compound tibia fibula fracture and had hardware removal in 4/25/2013.
Treatment plan includes epidural at the bilateral C5-C6 level, continuation with home exercise program and medications and follow up in 2 weeks.
Based on progress report dated 07/06/15, the patient presents with chronic right knee pain, described as dull and achy. Pain is worsened by sittlng,standing, and walking, and relieved by walking/exercise.
Identify the best radiological evaluation method for any of the following: Impingement syndrome, rotator cuff tear, and biceps tendon tear.
The plaintiff lives at 606 East 49th Street in Brooklyn with his mother, aunt and grandfather. He is currently employed by Sprint. At the time of the accident he was employed by Metro PCS, he had worked with them for 2 years prior to the accident as a customer service agent. He had health insurance but no fault paid his medical bills.
Medical Records Information: Swollen lower extremities, tender to palpation lower back, right knee and left shoulder. Limited range of motion neck and lower back. Unable to squat, unable to walk on heels and toes. Asthma, sleep apnea, obesity (11/21/2014 weighed 304.4 pounds), diagnosed with rheumatoid arthritis. Was receiving mental health treatment for major depression and chronic pain in the lower back and legs, pain was “becoming intolerable.” Also reported anxiety.
Patient has had progressive pain, numbness, and weakness in both lower extremities. He has had an epidural, physical therapy, and medications. It was reiterated that the patient has lost over 30 pounds. He has clear-cut instability as documented by the pars fracture and the spondylolisthesis, which is mobile on flexion/extension films.
This article presents a case report about a 31 year old male patient, a teacher at a university, who started experiencing mid back pain after weightlifting one day.3 About 3 hours after weightlifting, the patient began to feel sharp back pain, at levels T4-T8. His pain began to worsen that night causing muscle spasms of his paraspinal muscles, with intermittent radiating pain to his lateral thorax and chest.3 This patient had been diagnosed with thoracic facet injuries in the past, and just assumed it was that.3 However, after the pain did not subside the patient went to his physician who claimed the patient was just having muscle spasms and needed myofascial release.3 However, a radiograph was also done that revealed end plate degenerative changes at T7-T8.3 The patients clinical evaluation revealed muscle spasms of the paraspinal muscles between T3-T12, tenderness to palpate between T6-T8, full shoulder ROM, 5/5 shoulder muscle strength, and normal distal pulses and sensations.3 The patient was diagnosed with thoracic pain and muscle spasms and was give muscle relaxants and exercises for myofascial release.3 Three days after the physician visit, the patient decided to do some walking, to work on his cardio, and experienced mild shortness of
The original referral is sent to EHR. It was determined the patient should be outpatient status. The case is discussed with Dr. Levin and he does not agree, therefore this is second PA referral received on 1/16/2017.
DOI: 07/17/2013. This is a 25-year-old female cashier who incurred injury to her low back when she missed a step and fell off a ladder while stocking sleeping bags. MRI of the lumbar spine dated 10/03/2013 revealed broad based central disc protrusion at L4-L5; moderate discogenic edema along endplates at L4-5; and broad bulge with a central annual tear at L5-S1. CT scan of the lumbar spine dated 01/08/2014 revealed that at L3, bilateral pars interarticularis defects are seen with sclerotic margins. The vertebrae at L3-4 are normal in present on the prior MRI. The vertebrae at L3-4 are normal in alignment. At L4-3, there is 2 mm of anterolisthesis. Bilateral L4 pars interarticularis defects are seen with sclerotic margins. Office notes dated 06/28/2016
DOI: 01/31/2006. Patient is a 39-year-old male plumber who sustained a work-related injury to his back and elbow when he slipped and fell while going down the stairs. Per OMNI, he is status post lumbar fusion at L5-S1 on 7/19/10. The patient was declared permanent and stationary as of 8/15/11 with future medical care including physician visits, medications, possible surgery, bone growth stimulator, lumbar brace, and vocational retraining. On 12/18/12, he underwent removal of hardware and inspection of fusion.