Iw Case Studies

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.

The patient is a 36-year-old individual who sustained an injury on 01/30/17 due to lifting.

Tenderness is noted over the left lateral epicondyle. IW is still very tender over left bicipital tendon. IW has difficulty with left elbow flexion. Surgical scar well-healed and noted anteriorly, laterally, and posteriorly. Active shoulder range of motion (ROM) is limited with forward flexion to 70% of normal and abduction to 30% of normal. Internal rotation is 0% of normal.

DOI: 12/20/2010. Patient is a 63-year-old female compliance support specialist who sustained a work-related injury when she slipped and fell on wet tile floor. Per OMNI, she strained her left wrist, left shoulder and neck.

Per the IME report dated 09/02/16, the IW would need to be followed for one year to determine if operative intervention is indicated. If no surgery is done in 1 year, IW is basically committed to conservative treatment. He has not reached maximum medical improvement. He has had sufficient PT and can be on a home exercise program. He has a moderate partial disability of 50%.

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

DOI: 8/6/1997. Patient is a 56-year-old male chief engineer who sustained a work related injury when he fell on a level on or against an object. Patient is status post anterior lumbar interbody fusion at L3-4 and L4-5 with infuse, diskectomies with partial corpectomies and left cage instrumentation per the operative report dated 04/26/04.

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.

DOI: 2/3/1999. Patient is a 69-year-old male telephone sales representative who sustained a work-related injury to his knee when a co-worker came up behind him and knocked his knee to his. As per OMNI, an AME with Dr. Sommer dated 06/04/2001 noted that future medical care includes physician visits 3-4 times a year, pain and anti-inflammatory medications, gym membership, and epidural injections for back or possible nerve block. No treatment was noted to be needed for the psyche.

Regarding follow-up in 4 weeks; ODG states that evaluation and management (E&M) outpatient visits to the offices of medical doctor(s) play a critical role in the proper diagnosis and return to function of an injured worker, to monitor the patient’s progress, and make any necessary modifications to the treatment plan. 01/13/16 Progress Report noted that the patient has persistent neck, bilateral shoulder, mid back, bilateral upper extremity, lower back, and bilateral knee pain. The exam revealed that there were tenderness and muscle spasms about the thoracic spine. ROM of the cervical spine, thoracic spine and lumbar spine was decreased in all planes. There was tenderness over the bilateral upper cervical facet regions. Considering pain and functional limitations in multiple body parts, it seems medically necessary to monitor the patient and make any necessary adjustments to his treatment plan. Recommend certification.

01/27/16 Progress Report noted a follow-up visit. The patient continues to have right shoulder pain. The last injection helped him a lot. He also complains of horrible lower back pain. The patient states that the pain is so sharp that sometimes he cannot even sleep due to the pain. The exam of the right shoulder showed no TTP. The ROM was full. Neer’s and Hawkin’s tests were positive. The exam of the lumbar spine revealed a slight antalgic gait. He is slightly limping and uses a cane. There was exquisite tenderness noted throughout the lumbar paravertebrals worse at L5-S1.

DOI: 6/19/2003. Patient is a 57-year-old female clerk who sustained a work-related injury on 6/19/2003 to her back due to a motor vehicular accident.

Today was slightly different from my daily routine, however I really enjoyed it. Upon arrival I was asked by Noor to help develop a program plan for two new patients referred by the orthopedic doctor. The first patient had a partial thickness rotator cuff tear or rupture of the right shoulder. After evaluating the doctors referral, it was advised for this patient to seek Therapy 2-3 times per week for 8 weeks. It was noted that weight bearing as tolerated, therefore Noor and I decided it would be an good idea for the patient to exercise the shoulder with 1 pound weight bar, performing supine exercises for 1-3 minutes. The doctor also advised range of motion as tolerated- passive and active, therefore we concluded that the patient should perform

DOI: 7/7/2009. Patient is a 64-year-old female housekeeper who sustained injury while she was picking up a bag or garbage when she fell and hit her right rib cage on the table. Per OMNI, she sustained injury to neck, back, right shoulder, temporomandibular joint, and rib fracture. She underwent shoulder surgery on 8/09/12 and lumbar fusion on 12/16/13.

Per the medical report dated 12/20/16, the IW presented with left shoulder pain, worse when reaching overhead and when sleeping. He does feel that there