Male Forklift Case Study

Based on the progress report dated 03/28/16 by Dr. Bakhos, the patient presents for follow-up of his right knee

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.

He tolerates his medications without any side effects. He is taking Norco for moderate to severe pain. With Norco, he is able to walk 60 minutes longer, sleep longer and be more active. He can help take care of his kids with the help of his medications and standing. The pain is better with medications. He rates his pain as 10/10 without pain medications and 7-8/10 with pain

Physical therapy saw the patient, and the result of the examination are as follows; 6/10 left knee pain at rest and during activity (0 no pain, 10 worst pain), manual muscle testing for both upper and lower extremities were 4/5 except left knee flexion/extension 3+/5 due to pain, sensation on both UE/LE were intact to light touch, Stephen requires a moderate assistance of one person for both functional mobility and gait activity. He uses a front wheeled walker up to 35 feet due to decreased balance and antalgic gait from the left knee

DOI: 10/3/2013. Patient is a 51-year-old male bottling machine operator who sustained injury to his left knee when he hit it on an L-bracket after he stepped over a conveyor belt, missed a stool, and fell over. The patient underwent a left knee arthroscopy on 3/31/14.

DOI: 3/14/2014. Patient is a 57-year-old female lead operator who sustained a work-related injury when she twisted her right knee as she stepped down off a chase cart. As per OMNI, the patient was diagnosed with chronic right knee pain status post anterior cruciate ligament repair, and significant degenerative joint disease of the knee. She is s status post right knee anterior cruciate ligament (ACL) reconstruction on 07/15/14.

DOI: 2/3/2014. Patient is a 20-year-old male cashier who sustained injury to his right ankle when he slipped and fell. Per OMNI, he was diagnosed with right ankle sprain.

DOI: 9/26/2015. Patient is a 29-year-old male construction worker who sustained a work-related injury to his neck, back, left shoulder and right knee when he slipped and fell. He is status post left shoulder arthroscopy on 8/05/2016.

Treatment plan includes additional 6 acupuncture sessions as IW has reported 10% improvement, lumbar ESI at right L4-5, trial of Melatonin for sleep and follow-up in 4 weeks. Patient has completed 6 acupuncture visits with good benefit. She reports having fewer flare-ups after she completed acupuncture, improvement with pain symptoms and has increased range of motion and improvement in her flexibility and muscle strength.

He was prescribed with the following: Neurontin 600mg 3 tablets daily #90 as it decreases numbness, improves walking and activity tolerance and has no side effects; Zanaflex 4mg, 1 tablet daily as needed #5; Zohydro 10mg, 1 tablet daily #30 with 1 refill as it decreases pain from 9/10 to 6/10, improves walking and activity tolerance, no side effects, no abuse or aberrant behavior, consistent urine drug screen, signed medication agreement and receives pain medication from a single provider; Norflex 100mg, 1 tablet daily as needed #25 with 1 refill as it relieves muscle spasm episodes which allows for increase in walking, exercise, and activities of daily living; Vistaril 25 mg decreased to 1 tablet at bedtime #25 as it improves sleep and increases daytime activity tolerance (2 months supply). Patient will follow-up in 2

DOI: 3/31/2016. Patient is a 58-year-old male driver who sustained injury when he was hit by a vehicle. Per OMNI, he was diagnosed with right knee sprain/contusion.

O Exam note dated 06/08/2017 indicates: (objective exam findings). Diagnostic testing indicates an MRI of the left knee dated 10/27/2016 revealed a medial meniscus, radial oblique tear posterior horn adjacent to posterior root. There was bicompartmental arthrosis, advanced chondral loss on the medial femoral tibial compartment, and superficial chondral loss and medial facet of the patella. There was a large knee effusion with superior, medial, and infrapatellar plica. Prior treatment

He continues to use Percocet to manage his pain (30% pain relief) and allow him to function throughout the day which includes walking and getting to appointments. He does require albuterol at times.

Short term goals of treatment are to decrease pain by 1 scale, increase range of motion by 5 scale, increase muscle strength, re-establish functional activities/status and independence in activities of daily living. Long term goal is to have no

DOI: 01/23/2015. Patient is a 62-year-old male foreman who sustained injury when he slipped off truck's metal step, fell from 6 feet, landed on his tailbone, and hit his right head.