Dr. Fieser's Case Summary

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.

Physical therapy saw the patient, and the result of the examination are as follows; 6/10 left knee pain at rest and during activity (0 no pain, 10 worst pain), manual muscle testing for both upper and lower extremities were 4/5 except left knee flexion/extension 3+/5 due to pain, sensation on both UE/LE were intact to light touch, Stephen requires a moderate assistance of one person for both functional mobility and gait activity. He uses a front wheeled walker up to 35 feet due to decreased balance and antalgic gait from the left knee

Based on the progress report dated 08/23/16, the patient complains left knee pain upon walking. Discomfort was described as aching, tingling, intense, severe, continuous, pain, discomfort, increasing with movement and varying with activity. Pain is rated as 5/10 without medications and 4/10 with medications.

The patient stated that overall the symptoms have decreased. Antalgic gait has improved. The pain is decreased but it increases in the morning. The patient reported pain 3/10-scale level. Rom and Muscle strength remained the same. Swelling has decreased. Tenderness to palpation in the lateral and medial malleolus decreased. Muscle testing plantar flexion remains weak. Dorsiflexion remains weak. Review of Systems revealed joint swelling and loss of bladder/bowel control. Treatment plan included PT

Based on the progress report dated 08/26/16 by Dr. Boparai, the patient presents for left foot pain, rated as 2.5/10 with medications and 10/10 without medications. Quality of sleep is good. Activity level has remained the same. Patient is going to hyperbaric oxygen treatment daily and wound care clinic weekly for left foot amputation due to frost bite/gangrene.

Patient is diagnosed with pain disorder with related psychological factors and complex regional pain syndrome I of the right upper limb, chronic pain syndrome. He will follow-up in 4 weeks.

On Primary Treating Physician’s Progress Report (PR-2) dated 08/11/2017, the patient presented with unchanged symptoms. His left-hand pain was rated at 8/10. and was described as constant and sharp. The pain was aggravated with certain movements and gripping. The

Patient is unable to bear weight secondary to pain and swelling most prominently over the lateral malleolus, although the entire foot is somewhat swollen and hyperemic. He does have an ecchymotic area inferior to the lateral malleolus. Active range of motion. He is weak on dorsiflexion with adequate but somewhat diminished active range of motion on plantar flexion. He also demonstrates weakness on eversion and inversion although weaker with resisted inversion. On palpation, he is tender most prominently on the lateral aspect of the foot over the lateral malleolus not well localized with prominent tenderness over the ATFL and CFL, although

Based on the progress report dated 02/02/16, the patient presents for evaluation of his bilateral knee pain. He was last seen on 01/05/2016.

The patient is a 66-year -old retired black male. The purpose of the visit was to determine medication compliance, evaluate functional and mental status and perform a complete physical evaluation. His chief complaint is left knee and foot and calf soreness and ankle swelling without any injury for approximately seven days. He states that he has pain in his left knee, soreness to his calf increases with swelling and redness to his left ankle but no temperature changes to his left leg or foot. He states that his calf pain increases with dorsiflexion of his left foot. He describes the pain in his knee as pressure and rates the pain as 4/10. The pain does not radiate to anywhere other than his calf and knee.

Review of diagnostic studies and medical-legal reports is included in the physician’s notes. Objective findings note that the patient is mildly obese and appears to be in moderate pain. He does not show signs of intoxication or withdrawal. His gait is antalgic gait and is assisted by cane. Lumbar range of motion is restricted with 50 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral bending, and 10 degrees of left lateral bending. All range of motion is limited by pain. There is tenderness noted in the bilateral paravertebral muscles. Lumbar facet loading is positive on the left side. Ankle jerk is ¼ on the right and 2/4 on the left. Patellar jerk is ¼ on the right side and 2/4 on the left side. There is tenderness noted over the trochanter and pain to the lateral hip with range of motion. Right side motor strength of ankle dorsi flexor is 4/5 and ankle plantar flexor is 4/5. Hip flexor is 5-/5. Light touch sensation is decreased over the lateral calf on the left. Patient has resting tremor of the left lower extremity. His medications are Prilosec 20mg, Celebrex 200mg, Neurontin 800mg, Flexeril 10mg, Duragesic 75mcg/hour patch, Viagra 100mg, Nuvigil 150mg, and Silenor 6mg, Evzio 0.4 mg, and Norco

Patient has no joint pain .No crepitus assessed in both knees. No limitations in range of motion lower extremities verbalized and observed. Patient has no noted problem with gait

There is limited right ankle dorsiflexion with mild Achilles tightness. There are right ankle arthroscopic scars. There is positive ankle inversion test. There is tenderness at the subtalar, tibiotalar and right medial/lateral inframalleolar area. There is allodynia and mild hyperpathia.

Patient attends with increasing worsening discomfort in his right extremity as well as left lower extremity. The patient had a stenting done in 2010 he states of the right limb but they entered the left limb to stent the right limb. Fortunately, St. Cloud has sent off for his medical records and they have not arrived. Be that as it may, he has noticed over the past several months he has had increasing and worsening discomfort in his right calf with ambulation. Becomes rock-hard particularly if he is walking from his living unit to the dining hall. It is so hard that he has increasing and worsening discomfort while ambulating. When he finally reaches the dining hall where he can rest then it tends to improve. Walking back it is not as bad because it is a downhill walk. He does not have resting pain. The limb has not changed colors. He has not noticed dependency rubor. He states he also has a history of

As per progress report on 9/17/15, the patient’s current medications include Omeprazole, Naproxen and Gabapentin which decreases his pain about 60% and helps to control the pain and numbness in his left leg.