Iw Treatment Plan

sessions and IW has made great progress.

burning and throbbing pain from the knee down laterally. Physical examination revealed an antalgic gait with a limp. She is wearing a brace on the right knee. ROM of the right knee is decreased. There was tenderness to palpation over the right knee. Treatment plan included medications, increase hydrocodone 7.5/325, PT 3 X 8, MRI, and follow-up with surgery. Follow-up is in 1 month. 11/09/15 electro-diagnostic study described that the patient presented with right leg and knee pain with

awake. Some of the patient’s daily activities are being prevented by this symptom. He reports numbness and tingling in his right lower extremity. IW has been feeling better and was able to manage most of his pain with day long bed rest or medication at home. He notes that over the past few days, his pain has been getting worse and worse. He has not had treatment in over 8 months and

with punctured lung and 2 fracture of the lumbar discs. Patient is status pots L4-5 discectomy on 02/27/16 and L4-5 posterior pedicle screw fixation on 06/26/13. Per Ortho AME Dr. Ovadia, IW‘s shoulder is not P & S. Neuro AME Dr. Wang opined that the IW has 10% whole person impairment rating on 09/22/16. Per the Ortho Agreed medical Re-examination report dated 11/15/16, should patient finally have laminectomy and hardware removal, he will be re-evaluated for maximum medical improvement.

the right wrist with a heavy plastic shade while she was attempting to avoid falling. Patient is diagnosed with right radiocarpal sprain, right De Quervain’s tenosynovitis and pain in the limb. Per QME report dated 09/25/15 by Dr. Williams, the IW is taking ibuprofen and Norco occasionally. She has received conservative management and has reached MMI. She is P & S as of 09/25/15. Whole person impairment rating is 3%. Medical care includes continued office visit and some medications. Based on

throbbing. She also has 6/10 back pain. Sacroiliac belt increase her left hip pain. She also reports 0/10 elbow pain. IW admits to increased stress at home due to marital issues. She had carpal tunnel syndrome on the right and is pending on the left. Her primary care physician wrote her pain medications but she admits this cause itching and gastrointestinal distress. Prior treatments to the neck include PT and massage. On

12/02/14, the IW has attended 3 sessions. Based on the progress report dated 02/29/16, the patient is doing well but reports intermittent pain. He has had a lumbar ESI on 06/15 with no relief. On examination of the lumbar spine, range of motion shows forward flexion of 90 degrees and extension of 15 degrees. Manual muscle testing shows 4/5. Neurological examination is intact. Straight leg raise (SLR) testing is positive. IW was diagnosed with lumbar disc protrusion. Treatment plan includes new

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. Treatment plan includes continuation with therapy at 3 times per week working with postoperative treatments to the lumbar spine, follow-up with a neurologist regarding his headaches and dizziness, follow-up with a spine specialist and follow-up with a psychologist regarding his depressed mood. He can use

with a partial thickness articular surface insertional tear, moderate insertional infraspinatus tendinosis, mild acromioclavicular joint arthrosis and trace fluid seen within the subacromial/subdeltoid bursa. 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

compression; bilateral FABERE/Kemp’s standing and Patrick’s; Lasegue on the right; and straight leg raising on the right. IW ambulates with a cane. Gait is slow and antalgic. Diagnoses are cervical disc bulge, herniated disc and muscle spasm, lumbar radiculopathy, disc bulge, muscle spasm, myofascial pain syndrome, fatigue and right shoulder internal derangement. Treatment plan includes acupuncture to the neck, back and right shoulder, continuation with PT, home exercises, medications, K-laser