Kemp's Case Summary

DIAGNOSIS: Flexion contracture of the knee, quadriceps weakness, patellar tendonitis, contusion of knee, and knee pain

Impressions are lumbar discogenic pain syndrome, left lumbar radiculitis, myofascial pain, lumbar degenerative disc disease, and chronic pain syndrome and shoulder pain.

Komblatt, the patient underwent extensive chiropractic treatment with 87 sessions from 10/07/11 through 07/11/12. It was opined that it does appear that the IW ha s undergone excessive passive-chiropractic treatment referable to both lumbar spine and right shoulder. It was further opined that the IW has reached MMI regarding the lumbosacral strain and contusion of the right shoulder within approximately 6-8 weeks post injury. Appropriate treatment would have consisted of aggressive right shoulder and low back rehabilitation to include aerobic conditioning, strengthening exercises involving the right upper extremity, lumbar spine and core, and resumption of normal recreational and work activities within 6-8

IW was diagnosed with sprain of the ligaments of the cervical spine. Patient has received chiropractic care. Response has been good and IW is encouraged with gains being made. Improved function and functional restoration are expected with additional treatments. Plan is for chiropractic treatment, 2 times a week for 3 weeks.

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

Motor examination reveals 4/5 with left hip flexors/extensors/ abductors/adductors and knee extensors/flexors, 4-/5 with left ankle dorsiflexors and plantar flexors and 3+/5 with left external hallucis longus (EHL).

Dr. Nilssen will examine the patient’s foot to find the location from which the pain is stemming. He will also perform tests to determine the stability of the injured area(s). Dr. Nilssen may order a series of foot and ankle X-rays. These X-rays will show whether or not a patient has shifted and/or broken bones within the foot. In addition, patients may receive an order for a Magnetic Resonance Imaging (MRI) test; whereas, an X-ray shows the bones of the foot, an MRI shows the ligaments of the foot. Furthermore, patients may receive a computed tomography (CT) scan to assist in determining the extent of the injury to the bone. A CT scan is also beneficial to Dr. Nilssen when a patient requires surgical

Per the IME report on 4/28/16 by Dr. Pierce Ferriter, the patient reports that he is actively treating with physical therapy and chiropractic treatment at a frequency of 3 to 4 times per week. The patient’s diagnoses include resolved lumbar strain, resolved cervical strain, resolved left shoulder strain and resolved right knee strain. There is no medical necessity for further physical therapy, orthopedic treatment of diagnostic testing based on examination.

Therapeutic exercises are indicated for the same reasons of increasing strength, increasing range of motion, and promoting normal movement patterns allowing this patient to increase her endurance to ambulate, increase her ability to sit, stand, twist, and bend. Indications on this examination of continued muscular spasms throughout the joints, trigger points, adhesions, and neural compression warrants soft tissue mobilization.

As per medical report dated 3/10/2016, patient complains of low back pain rated at 7/10 with left lower

On examination of the lumbar spine, there is tenderness at L4-S1, with spasms noted. Straight leg raise (SLR) is positive on the left side. As of this report, a urine drug screen was consistent with prescribed medications.

DOI: 8/26/2007. Patient is a 46 year-old male general production worker who sustained a work-related injury to his left ankle as a result of walking over an uneven driveway. The patient was subsequently diagnosed with tendonitis and degenerative joint disease. As per SOAP notes dated 7/6/16, the patient complains of ankle pain and that he is out of medications. Objective findings reve3aled pain with motion and while in cast. It was further noted that it seems to cycle and stable. Motion in the “STJ” residual from failure of fusion pain producing relative to time on it, in cast/out. Plan notes that left ankle lateral aspect is the area of tenderness. Current medications are Norco and

On examination, there is tenderness on palpation of the lumbosacral area. There is lumbosacral spine pain elicited by motion. Lumbosacral spine motion was normal with mild pain. Sensation to light touch is decreased over the dorsal aspect of the left great toe. Assessments are lumbar sprain and left L4-5 herniated disc. Patient was provided a script to continue with PT.

IW was diagnosed with sciatica, other signs and symptoms involving the musculoskeletal system, chronic pain syndrome, difficulty in walking, low back pain, lumbar degenerative disc disease, bulging lumbar disc and lumbar facet

Due the patient’s symptom reproduction with the straight-leg-raise test, the SLR measurements remaining between 30-60 degrees hip flexion, the positive slump test, the described radicular pattern, and diminished Achilles DTR the therapist concluded that the examination findings were consistent with the medical diagnosis of L5/S1 disc herniation with associated nerve root involvement. (CITE) Therefore, the physical therapists diagnosis was practice pattern 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders. (CITE) Once tested, the sacroiliac (SI) tests determined SI joint dysfunction which warranted interventions to improve SI joint mobility. (CITE)