Work Related Injury Case Summary

Based on the progress report dated 01/21/16, the patient complains of intermittent and worsening right shoulder pain, rated as 8/10. Pain radiates to the left arm, described as aching, burning and sharp. Pain is aggravated by lifting and movement, and relieved by rest. Associated symptoms are decreased mobility, and joint instability and

Based on the progress report dated 03/21/16, the patient reports that his low back pain tweaked again, after making the bed. He went to the emergency room last week and was provided with Toradol injection. He was told it was sciatica on the right leg. Now, it is in the center of the back and sacroiliac area. Current pain level is 8/10 with pain medications. He also reports that the left side of the back and leg is aggravated by sitting between 1 to 1.5 hours.

She is oriented x3, alert and cooperative. Good short-term, long-term and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration.

EXAMINATION: He continues awake and alert. He converses easily and appropriately. He is in no acute distress. Blood pressure 120/78. Pulse 70 and regular. Weight 177 pounds. Height 5 '6". Cranial nerves continue intact, including the extraocular eye movements being intact without nystagmus. Visual fields are full in both eyes. He had no papilledema or atrophy of either optic disc. Pupils react from 4 down to 2 mm, bilaterally brisk and round to light and accommodation. He continues to have good strength with normal bulk and tone throughout his extremities. He had normal sensation to light touch, pinprick, and vibration sensation throughout both upper and

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.

Per the progress report dated 5/18/16, the patient complained of low back and left leg pain. Percocet decreases pain by 80% and enables him to perform light gardening and household chores. No side effects with Percocet use. He is doing well with current medications and is compliant with no aberrant behavior. Upon lumbar examination, motion is associated with increase in pain. Left seated straight leg raise is slightly positive. There is decreased sensation of the left anterior thigh. He has forward leaning stiff gait with ability for heel and toe rise.

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.

The patient is a 68-year-old gentleman who had a fall from a standing position. The history is vague, however he details it better with the neurologist. He relates to the neurologist that he was sitting on the couch, he felt dizzy, he got up to go to the bathroom and then had loss of consciousness found himself on the floor with laceration to his head. He could not get up, but he was able to call his daughter on the cell phone to help him. The patient in the fall, dislocated his right shoulder which was taken care by orthopedics.

P-No appointment was scheduled until the patient is sure about his ongoing treatment at the clinic. This writer strongly advised the patient to continue to adhere to the program policy as it is crucial to his recovery process and the sole purpose as to why he is

12/01/15 follow-up visit identified lower back pain. Patient rates the pain as 7/10. The pain is characterized as burning. It radiates to the neck and upper back. Condition is associated with back pain and difficulty in ambulation. It is aggravated by bending over, lifting, prolonged sitting, prolonged standing and prolonged walking. Application of cold, application of heat, bending forward, medications and rest, relieve the pain. Medication side effects include nausea and vomiting. Patient’s primary care doctor stopped her oral medication due to nausea and vomiting; and her liver function tests were elevated. She does not know names, but the sleep aid and the oral medication for pain during the day were stopped. She tolerates the medications well. Patient shows no evidence of developing medication dependency. Patient does not feel the current medication she is taking adequately addressing her pain needs and would like to try a different medication. The level of sleep for the patient has decreased due to difficulty in failing asleep and due to

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

Bill is a 34 year old male who has recently been prescribed analgesic and muscle relaxant for his right hip pain. After three weeks of pain he is still experiencing symptoms. However, he is now experiencing stiffness and pain in his left hip as well.

Every medication has a side effects and adverse effects. In this case, treatment choices fall into four categories: pharmacologic, nonpharmacologic, surgical and complementary (Sinuasas, 2012). In this patient’s situation, pharmacological treatment should begin with acetaminophen and gradually move up to nonsteroidal anti-inflammatory drugs. NSAID therapy is recommended as a first line therapy for minimum to mild arthritis. However, since the patient indicates GI distress to NSAID medication (Naprosyn), other NSAIDS medications may be utilized. According to Sinusas, “acetaminophen should be used as first-line therapy for mild osteoarthritis; NSAIDs as a class are superior to acetaminophen for treating osteoarthritis and patients taking NSAIDs should be cautioned about adverse effects, which may include gastrointestinal bleeding, renal dysfunction, and blood pressure elevation” (2012, p.

Per medical report dated 06/16/2015 by Dr. Lemley, the patient complains of pain and dysfunction to bilateral hands/wrists. She has right greater than left discomfort in her thumbs with numbness.

During assessment, she stated that she usually experiences pain intermittently on the left side of her body, as well as her lower back and that her hip feels dislocated. The patient was not sure of how to rate her pain on a scale with 1 being the lowest and 10 being the highest, however, she stated that the pain worsens with movement and the pain is not relieved whenever she receives her medication. The medications given to her are: panadine and voltaren. The patient also states that there are no associated factors with the pain.