Informatic Cancer Case Write Up

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.

DOI: 12/3/2012. The patient is a 49-year-old male route sales representative who sustained a work-related injury to his lumbar spine and shoulders while lifting a bread rack out of his truck. Patient is status post bilateral L4-5 laminotomy, complete facetectomy and foraminotomy on 01/14/15.

Dr. Abiera had reviewed a September 3, 2010 MRI of the cervical spine that revealed central protrusion/herniation at C3/C4, left paracentral protrusion/herniation at C7/T1, Disc bulges C4/C5, C5/C6 and C6/C7, left paracentral extrusion/herniation at T3/T4 and straightening of cervical lordosis. In addition, Dr. Abiera noted an August 11, 2010 x-ray of the cervical spine which revealed blastic lesions, incidental Clay Shovelers Fractures of C7 and an August 11, 2110 x-ray of the thoracic spine which was

Based on the progress report dated 10/07/16, the patient presents for evaluation of carpal tunnel syndrome on the right shoulder.

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

Based on the latest medical report dated 02/10/16, the patient has undergone extensive PT. She was diagnosed with sprain/strain derangement of the cervical spine, cervical subluxation complex, and cervical brachial radiculopathy, sprain/strain derangement of the lumbar spine, lumbar subluxation complex and lumbar radiculopathy.

DOI: 2/24/2016. Patient is a 46-year-old male production technician who sustained injury while he was lifting a heavy door when he felt immediate pain in his right shoulder. Per OMNI, he was initially diagnosed with right shoulder strain.

Patient continues to manage pain with medications which brings the pain intensity from 7/10 on an average down to 3-4/10 and allows her to continue activities of daily living (ADLs) with less pain and stiffness. Patient states that without medications, she will not be able to function or move due to increase pain

Examination of the bilateral shoulder reveals tenderness to palpation about the anterior shoulders bilaterally. There is also restricted range of motion secondary to pain and her supraspinatus weakness and Hawkins’ impingement tests are both positive. In addition, Neer’s impingement and drop-arm tests are also positive.

DIAGNOSIS: Strain of muscle, fascia, and tendon at neck level; Carpal tunnel syndrome, unspecified right limb,;Carpal tunnel syndrome, unspecified left limb; Status post left carpal tunnel release; and Adhesive capsulitis of right shoulder (M75.01).

DOI: 03/11/2009. Patient is a 60-year-old male truck driver who sustained a work-related injury to his back when he tried to catch a box from falling. He is status post two back surgeries on 07/06/2009 and has reached Maximum Medical Improvement as of 06/19/2012.

Per verification from the provider’s office, the patient has no recent urine drug screen as they are still waiting for approval and Soma was initially prescribed on 05/05/16.

DOI: 5/12/2016. Patient is a 30-year-old female “WNA 2” who sustained an injury while she was driving, a vehicle rear-ended their vehicle and she injured her back, neck and right arm. As per OMNI notes, the patient is diagnosed with cervical/thoracic/lumbar strain and right upper limb pain.

On examination of the lumbar spine, there is moderate to severe muscle spasm and tenderness of the paraspinal muscles and spinous process at L4-5. There was painful active

DOI: 2/25/2015. The patient is a 49 -year-old male service technician who sustained a work-related injury to his neck, bilateral shoulders and back when his truck was hit in the back by a plow pick-up truck.