Cortisone Case Study

DOI: 02/27/2014. The patient is a 63-year-old male driver who sustained lower back injury while unloading foods and fell between the loading dock and rear trailer.

DOI: 12/19/2012. Patient is a 52-year-old female laborer who sustained injury to her neck, back, and right shoulder due to motor vehicle accident. Per OMNI, she underwent an emergency neck surgery with 5 screws at C5-7 and back fusion and rod placement at T8-10.

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

Based on the medical report dated 12/22/16, the patient was last seen on 10/13/16, and was recommended to have continued therapy. He has not had therapy secondary to insurance issues over the last month or so. He presents with ongoing right elbow pain status post cubital tunnel release and medial epicondylitis debridement, worsening with motion and activity, lifting, reaching, bending, upper extremity dressing, household

Based on the latest follow-up evaluation progress report dated 03/02/16, the patient complains of right shoulder pain and stiffness. He states that his shoulder feels sore. He states that his pain is aggravated by the cold weather and over activity. The patient has not attended physical therapy for some time due to travel outside of the country. He is using an analgesic cream.

DOI: 9/4/2014. The patient is a 51-year old male paint maker who sustained a work-related injury when he missed a step on a platform and fell, jarring his back. As per OMNI entry, he was diagnosed with lumbar sprain and lumbosacral disc degeneration.

DOI: 9/26/2015. Patient is a 29-year-old male construction worker who sustained a work-related injury to his neck, back, left shoulder and right knee when he slipped and fell. He is status post left shoulder arthroscopy on 8/05/2016.

S: In 10/22/2014, TM was seen for bilateral shoulder pain. Today TM is here complains of left shoulder pain. According to TM he was aligning a Santfa, a process involving reaching. When he was bring his arm down, he felt the sharp, tearing pain in his anterior of his shoulder. TM is here with left shoulder pain. TM reports his pain at 6-7/10. The pain was sudden, sharp at The pain was localized, and didn’t radiated to anywhere else. The pain was so sudden and so severe, it scared him. TM denies any tingling or numbness, loss of movement.

Based on the progress report dated 03/10/16, the patient complains of continued pain over the lateral epicondyle. He has completed 3 PT sessions to date with no improvement. Pain is radiating from the elbow towards the shoulder and hand, rated as 8/10. Review of systems is positive for joint pain and bronchitis.

Diagnoses are cervical radiculopathy, right shoulder pain, nondisplaced fracture of the greater tuberosity of the right humerus and right shoulder bursitis. He has reached maximal recovery for his right shoulder. MD is concerned that the elbow and hand pain are related more to his neck as he has a history of cervical radiculopathy and his symptoms are more of tightness than pain that can be localized. He has had epidural injections in the past for left sided radiculopathy. An updated MRI is requested. If there are right-sided findings, he will be sent for possible injection for the upper extremity pain. Otherwise, he will be sent for a second opinion for his continued

DOI: 11/3/2016. Patient is a 54-year-old male maintenance worker who sustained injury when he lifted heavy trash bags out of a garbage can and strained his neck. Per OMNI entry, he was initially diagnosed with neck strain.

The first was a questionnaire for symptoms, disability, and the SF36 health survey. The second assessment was performed by a blinded orthopaedic specialist and third an ultrasound and MRI of the shoulder. In the first stage the subjects took a Nordic- style questionnaire that focused on pain in the upper limb. The second stage was performed by an experienced orthopaedic specialist. The specialist assessed both shoulders by determining the range of motion and pull force at a 90 degrees of abduction in the scapular plane. A constant score was calculated for both shoulders. If the constant score was below normal female values, their shoulder was considered abnormal. Third a blinded musculoskeletal radiologist performed an ultrasonography of both shoulders in all subjects. If they had an inconclusive finding they completed the assessment with an MRI. The subjects were not allowed to report any pain they were having during the

01/26/16 Progress Report noted that the patient presented with left shoulder pain. The pain was gradual in onset and is constant. The pain is characterized as burning, sharp, shooting, and throbbing. It radiates to the neck. She described her pain as moderate to severe. Her condition is associated with numbness in her left fingertips and weakness in her upper extremities. Any activity, movement and reaching aggravate the pain. Stretching and hot showers relieve the pain. The level of sleep has been decreased due to difficulty falling asleep. The quality of sleep is poor. She has difficulty performing her ADLs. Current medications: Meloxicam, Naproxen, and Spironolactone. Review of Systems was positive for weakness and nausea. The patient also has anxiety and depression. She has had psychiatric, psychological, or social work evaluations or treatments for problems. The physical exam of the cervical spine revealed that the ROM is restricted. There were spasms and tenderness of the paravertebral muscles bilaterally. There was also spinous process tenderness noted on C6 and C7. Tenderness is noted at the paracervical muscles and trapezius. Spurling’s maneuver produces no pain in the neck muscles or radicular symptoms in the arm. Adson’s test is negative. No signs of meningism. Cervical facet loading is negative on both sides. The exam of the right shoulder was

SUBJECTIVE: The patient is a 27 y/o African-American male with no pertinent past medical history who presents today for evaluation of left shoulder pain. Patient is a full time theatrical dancer that states the pain started 6 months ago shortly after his employment. His pain is worsened after work and is exacerbated by overhead movements. He describes the pain as an intermittent dull pain, 6/10 that occasionally wakes him up at night. He denies any recent trauma. The patient notes in the past he used Tylenol 500 mg daily with no relief.

DOI: 5/31/2016. Patient is a 58-year old male foreman who sustained a work-related injury to his neck, back, and pelvis due to a motor vehicle accident.