Medical Case Study: Wound Injury

Attend the next appointment with Dr. Taha on 10/24/17 to address work status, bone healing, replacement services, attendant care. Obtain projections for recovery.

Range of motion shows flexion of 85 degrees, extension of 30 degrees, and lateral tilt of 25 degrees bilaterally. Straight leg raise is positive on the right at 90 degrees for low back pain. Bechterew's test is positive on the right. The patient has diminished sensation in the right L4, L5 and S1 dermatomes. Deep tendon reflexes are absent in the right knee and right ankle.

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,

On 9/28/17 I spoke with C. Weaver physical therapy. The physical therapist advised that they do not offer occupational therapy just physical therapy. They also are not equipped to do more than one body part at a time. In reviewing the records and the FCE I had supplied them they determined she is not in the best location. They recommend Hope Network. I have contacted Hope Network and confirmed that this would be a more appropriate location for the 5 days a week therapy she needs and what the FCE had suggested. I have contacted Dr. VanderJagt’s office and requested an order for the therapy.

Per PT treatment log dated 11/18/15, the patient has attended 19 PT visits for the thoracic and lumbar spine from 08/27/15 through 11/13/15.

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

DOI: 3/24/2011. Patient is a 47-year-old male station manager/mechanic who sustained a work-related injury to his neck, back, bilateral shoulder, right elbow and left wrist when he was mounting a tire and the tire kicked back.

DOI: 12/23/2013. The patient is a 64-year-old male foreman who sustained injury when he was involved in a motor vehicular accident. Per OMNI, he has had multiple injuries to the right shoulder, right knee, back and right arm/elbow. He is status post arthroscopic surgery for the right shoulder on 05/30/2014.

Current request is for 12 Physical Therapy Visits for the Left Shoulder between 1/17/2017 and

DOI: 11/16/2010. The patient is a 60-year-old female floor person who sustained a work-related injury when she slipped and fell on unknown slippery surface.

Objective Functional Improvement shows that the patient is now able to get dressed with minimum assist. He is also now able to navigate 2 flights of stairs without pain, same as prior, now able to walk for 8 minutes, same as prior, can now lift 6.5 lbs. of weight, improved from prior, and push 6 lbs. of weight, same as prior. Therapy goals for this patient in the next 4 weeks are to reduce inflammation from moderate to minimal and increase cervical and lumbar spine flexion and bilateral rotation by 3 degrees. The patient in the next 4 weeks will be able to get dressed easier, navigate 2.5 flights of stairs without pain, walk 9 minutes from 8 minutes, lift 7 lbs. of weight, and push 7 lbs. of

DOI: 6/23/2015. Patient is a 44-year-old male assembler who sustained injury while he was reaching for a part, pulled axle from rack and felt pain in the cervical spine. Per OMNI, the patient is diagnosed with acute cervical sprain and cervical radiculopathy.

Based on the latest medical report dated 03/14/16, the patient returns for a follow-up visit and reports low back pain with radiation to the right lower extremity with stiffness. She felt difficulty with flexion and decreased flexibility.

DOI: 11/20/2015. Patient is a 26-year-old male laborer who sustained injury while he was moving a 12 x 12 timber with a co-worker when the weight shifted to his end, causing him to fall backwards and the timber struck him. Per OMNI, he was initially diagnosed with right knee contusion.

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.