Injury Case Studies

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

On Exam:  BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the

Williams, the patient reports occasional low back pain that he rates from 0-3/10. On this visit, he has no low back pain.

Patient reports no weight fluctuations. Denies fatigue, malaise, weakness, sweats, night sweats and chills. Patient reports mild left leg weakness secondary to left tibia fracture June 2012, but ambulates well and is able to be active in school sports, hiking, biking, and swimming. Patient reports working on building strength in left leg through sports and recreational activities. Patient reports asthmatic exacerbations with exercise. Patient reports trying to build lung capacity by running and swimming which exacerbates his asthmatic condition and uses inhalers.

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

An attending physician statement completed by Dr. Peter Chweyah (Internal Medicine), dated 06/16/2016, indicated that the claimant presented with complaints of lower extremity weakness, neuropathy, weight loss, acute renal failure, and gout, as well as anemia. Objective findings showed an extreme weakness of the legs and pain in the feet. He also had diabetes mellitus type 2, chronic kidney disease, and hypertension. It was noted that the claimant was totally disabled from 05/30/2017 through 06/15/2017 and 05/23/2017 - 05/26/2017 secondary to gout.

12/24/15 Progress Report describes that the patient has right knee pain. The pain is frequent. It is aching and burning in quality. The current pain level is 0/10 and worst pain is 4/10. Bending, squatting, walking, weight bearing, changing clothes and ROM aggravate the pain. Rest, ice,

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

Per verification to the provider’s office IW has had 13 PT visits for the back from 10/13/15 through 12/31/15. Requested for recent PT notes, however, no medical records received at the time of submission of the review to PA.

MEDICAL UPDATE: Client continues to report arthritis in her left leg and hand, high blood pressure. She also reports she will need surgery but she is waiting to be housed.

The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.

Per the Agreed Medical Re-Examination report dated 09/29/15, whole person impairment rating is 5%. Future medical care includes access to follow-up visits for monitoring of his condition for the next calendar year, with continued provision of pharmacological agents. Should patient experience a significant acute symptoms flare-up within the next calendar year, re-instatement of brief courses of traditional PT, acupuncture,

DOI: 9/30/1997. The patient is a 50-year-old female reservation clerk who sustained a work-related injury to her back and bilateral lower extremities when she tripped and fell.

My diagnosis for the patients injury is medial tibial stress syndrome. I believe this due to the positive special test and the palpation’s. The compression test was positive with pain on the medial distal one third of the tibia. The fulcrum test was the most positive out of the two with the patient pulling back from pain. Also with the palpation's, he had point tenderness over the medial distal one third of the tibia (1985).

HISTORY OF PRESENT ILLNESS: Ruby Pearce follows up today for reevaluation of her left proximal humerus fracture sustained secondary to a fall on July 9, 2015. She was seen in the office on July 15, 2015 and a course of nonoperative treatment for proximal humerus fracture was begun. She was given a prescription for physical therapy and instructed on home exercise program including pendulum motions and wall walking. She has not attended physical therapy, but has been diligent with her home exercise program. Her pain is intermittent and sometimes sharp, but is easily controlled with medications. She states she has a 5-6/10 at times. She takes Tylenol to control these symptoms. She notes no neurovascular