A Case Study Of The Diagnosis Of Managed Care

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The patient is a 54-year-old individual who sustained an injury on 03/07/17 due to a fall.

The recent diagnoses included a sprain/strain of the cervical, thoracic, and lumbar spine, a sprain/strain of the right shoulder, rule out rotator cuff tear, a sprain/strain of the right elbow, rule out cubital tunnel syndrome, a sprain/strain of the right wrist, rule out carpal tunnel syndrome, De Quervain’s disease, and a sprain/strain of the right hand, knee, ankle, and foot.

Treatments rendered to date included medications.

The most current medication regimen included Cyclobenzaprine and Acetaminophen. Her past medical history was significant for pre-diabetes, hypertension, and high cholesterol.

Medical records reviewed included Doctor’s
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The Soto-Hall’s test was positive. Her thoracic spine examination documented tenderness to palpation in the spinous processes of the thoracic spine. Lumbar spine examination revealed tenderness to palpation in the paralumbar muscles associated with spasm. The lumbar spine range of motion revealed a flexion of 45°, an extension of 20°, and lateral bending of 20°, with pain in all planes. Bechterew’s test was positive for low back pain. Her right shoulder examination documented tenderness to palpation in the upper trapezius and rotator cuff muscles. The Drop arm test was questionably positive. Her right shoulder range of motion revealed a flexion of 160 degrees, an extension of 40°, abduction of 160°, adduction of 50°, external rotation of 80° and internal rotation of 80°, with pain in all planes. Her right elbow examination revealed tenderness to palpation. Her range of motion revealed flexion of 140°, extension of 0°, forearm supination of 70°, with pain in all planes. The tennis elbow test was questionably positive. Tinel’s sign was also positive. Her right wrist examination revealed tenderness to palpation. Right wrist range of motion revealed a palmar flexion of 50°, dorsiflexion of 50°, as well as radial and ulnar deviation of 20°,with pain in all planes. The Tinel’s sign was questionably positive and the Finkelstein’s
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