Case Summary: Occupational Injury

DOI: 12/5/2013. The patient is a 57-year-old female precertification technician who sustained a work-related injury to her head, neck, lumbar spine, and right knee after slipping and falling on icy sidewalk. As per OMNI entry, she was diagnosed with head/scalp injury, status post concussion, cervical strain, headaches, and right knee medial meniscal tear status post surgery on 06/04/2014.

The patient wants to also update me as far as the arm pain he mentioned last time. He says his left arm is feeling better now. He is noticing that his right shoulder is hurting at times, especially in certain positons such as while he is sleeping and if he has his arm raised over his head while he is lying down. He had no specific injury or trauma. He is not aware of anything that makes it better or worse. He is not using any medication for it thus far. He would be interested in having

A physical therapy evaluation dated 08/07/2017 indicated that the claimant had a right shoulder pain after a fall onto her elbow and knee at work on 06/28/2017. She stated that she will have a surgical intervention on her right shoulder. She rated the pain at 6-8/10. She was unable to reach above her right with the right upper extremity. Objective findings showed reduced right arm swing. It was noted that the claimant was unable to place the right hand behind the head or the ear. There was a noted atrophy of the right forearm. Therapeutic exercises, moist heat, TENS, cryotherapy, and patient

Patients experiencing lateral epicondylitis usually experience gradually increasing elbow pain. Upon palpation , sharp pain can be detected at the lateral epicondyle of the humerus and possible tenderness of the common extensor musculature of the forearm.(1) To further diagnose the patient , further positive provocative testing is to be done to confirm if the source of pain and discomfort is lateral epicondylitis. The 2 most commonly used tests to identify tennis elbow is the Mill’s test and Cozen’s test.(1)

Per the initial orthopedic evaluation report dated 02/09/16, the patient’s pain is worsened when he attempts to elevate the arm. Pain and weakness in his arm make it difficult for him to perform activities such as dressing, grooming and bathing. He is taking

DOI: 12/1/2003. The patient is a 58-year-old female book keeper who is experiencing pain in her right arm and wrist due to performing her usual and customary job duties. Per OMNI, the patient is diagnosed with neck pain and bilateral upper extremity pain. The patient is subsequently diagnosed with lateral epicondylitis, right elbow; lateral epicondylitis, left elbow; radial styloid tenosynovitis; and enthesopathy, unspecified. As per medical report dated 6/23/16, the patient walks in due to worsening of symptom. She has worsening pain in the right upper arm, forearm, medial, and lateral elbows, and left upper arm, forearm, medial, and lateral elbow, right more than left. Pain is burning in nature and constant. Any gripping/grasping activity

Based on the medical report dated 04/11/16 by Dr. Au, the patient complains of neck pain and presents for a cervical epidural steroid injection. Pain is rated as 5/10 and described as stiff, tight and achy. Pain is worse with turning his head. He continues to do PT for his neck pain and shoulders with benefit.

Impressions are the following: cervical disc bulge and disc protrusion; left C6 radiculopathy; bilateral shoulder tendinitis impingement status post left shoulder arthroscopic procedure on 08/12/12; right shoulder arthroscopic procedure on 04/04/13; lumbar disc herniation; right L5 radiculopathy; lumbar discectomy on 07/17/13; lumbar fusion on 03/24/15; cervical and lumbar myofascial derangement; right elbow lateral epicondylitis; left wrist sprain status post left wrist carpal tunnel release; cervical and thoracic myofascial derangement; status post right carpal tunnel release and tenosynovectomy; status post cervical anterior cervical discectomy and fusion (ACDF); and status post recent right cubital tunnel release.

I was drawn to your posting because I am currently treating a patient with the same diagnosis. He is a construction worker, and given the nature of his job which usually involves recurring movements using a screwdriver. Given the frequency and forceful forearm supination and pronation, and/or extension of the forearm and wrist this has resulted

Based on the doctor’s first report of occupational injury by Dr. Bazel dated 01/07/16, the patient complains of pain in the lumbosacral region which radiates to both legs. She also reports pain in the lower extremity and bilateral hips.

DOI: 5/6/2015. Patient is a 56-year-old female assembler who sustained injury while she was reaching for a tire when she slipped and hit her wrist on tire. Per OMNI, she was initially diagnosed with left wrist contusion.

S: TM works in GA Final B; Door Sub. According to, TM, his right shoulder began to hurt on right Thursday, he thought, over the weekend with adequate rest, ice and some Advil will get him better, but his right shoulder didn’t get better but worse. That’s when he decided to come to HMMA Medical Clinic. TM reports his right shoulder pain is 7/10, he couldn’t even perform his ADL this morning because he couldn’t raise his right arm above his waist level because of the pain. TM reports his pain is in his AC, deltoid region, and pectorals major area. TM denies acute trauma or previous injury to the location. TM denies numbness or tingling sensation radiating down to his hand

The patient is a 42-year-old white male with a history of right shoulder pain for approximately 6 months. He had tried physical therapy and had 2 prior injections into the shoulder which provided transient release of his shoulder pain. His past medical history is significant for some other problems in his left shoulder which did not respond to conservative therapy but responded well to a left shoulder arthroplasty subacromial

DOI: 02/11/2016. Patient is a 50-year-old male carpenter who sustained a work-related injury while at work. The patient was subsequently diagnosed with contusion of scalp, initial encounter; and Sprain of other ligament of right ankle, initial encounter. Per medical report dated 4/21/2016, the patient complained of frequent severe pain in the head and lumbar spine that was described as sharp. The headache is associated with dizziness. The patient has completed 12 physical medicine sessions to date and showed significant functional improvement as manifested by increased activities of daily living. The patient was then declared temporarily totally disabled until 6/21/2016. As per progress report dated 6/2/16, the patient complains of frequent

DOI: 5/2/2016. Patient is a 43-year-old female production worker who sustained injury while she was pulling a coil stacked in a machine when she slipped and fell. Per OMNI entry, she was initially diagnosed with strain to the upper back and right shoulder.