Middle Finger Contusion Report

S: TM works in GA Final when she closed the Sante Fe’s back door on her left pointer finger. TM rates her pain at 10/10 pulsating type pain. After 20 minutes of ice TM rates her pain at 7/10. TM reports initial bleeding, copious amount from her left pointer finger distal phalanx. TM denies previous injury to the location.

Patient is a 57-year-old male fuel tank driver who sustained cumulative trauma on 2/7/2004 due to repetitive movement caused by delivering fuel. As per QME dated 1/25/14, the patient has numbness in the fingers and the patient is diagnoses that he has carpal tunnel syndrome. The left wrist had undergone carpal tunnel surgery; however, he gets numbness from the wrist up into his forearm and numbness in the fingertips. It was also noted that on 12/5/13, the patient complains of shoulder pain bilaterally at 7/10. It is constant and goes into noth arms, along with weakness with numbness in the hands, decreased ability to perform activities of daily living, and impared grip. The pain in the bilateral shoulders is constant and aching with intermittent

Temp 97.5, blood pressure 123/83, O2 sat 95% on room air, pulse 81. Alert male, no acute distress. Pleasant and cooperative. Pupils equal, round, react to light. Examination of the scalp reveals laceration on the posterior scalp. Wound edges well approximated

DOI: 6/12/2014. Patient is a 59-year-old right-handed male machine operator who sustained work-related injuries to his right arm, shoulder and neck when his right hand got caught in a mixer. As per office notes dated 9/6/16, the patient returns complains of continued neck pain with burning hot pain extending into the forearm down to the hand along the C6 and C7 distribution with numbness and tingling in the hand. The patient has undergone multiple medications, physical therapy, TEN both in physical therapy and home use. It was also noted that the pateint denies having cognitive behavioral therapy. The provider notes, that it would be appropriate as based on the history including postoperative right forearm fracture repair and forearm open reduction and internal fixation of the right distal radius that an additional surgery to the right arm and continue physical therapy, yet continues to have swelling

O: Inspection of the right shoulder, no redness or edema noted; palpation of the right shoulder there was no warmth noted; on deep palpation TM reports in some tenderness

S: TM just finished working on a car in the back step off platform into pit, wielding AN Car, and fell back on pipes on his left lateral side. The initial pain was 10 out of 10 and it was difficult to breath related to pain. Now, he rates his pain at 5 to 6 out of 10, aching paint to his left shoulder and his left lateral rib cage. Denies any headache, blurred vision, N/V. Ice X 20 minutes now did helped him with symptoms management.

On Primary Treating Physician’s Progress Report (PR-2) dated 08/11/2017, the patient presented with unchanged symptoms. His left-hand pain was rated at 8/10. and was described as constant and sharp. The pain was aggravated with certain movements and gripping. The

DOI: 11/17/2015. Patient is a year old male mechanic who sustained injury while he was throwing a broken urinal into dumpster when it broke and cut his left wrist. Per OMNI, he was initially diagnosed with laceration to left wrist/forearm flexor tendons to middle, ring and pinky fingers. Surgery was done on 11/25/15 for left forearm repair.

CM Gilmore met with Bmo and VC are several attempts to make contact to ensure safety and well-being. CM addressed the allegations in the report regarding the PKU screening of the infant. She reported that she didn't use the doctor that was recommended at the hosptial, because of the distance from her residence to the doctor's office. She reported that she changed doctors. She reported that she has been missed three appointments. Bmo was able to provide proof of immunization records regarding the required shots the child is supposed to have at her age. CM Gilmore found no safety concerns in the home. CM Gilmore discussed safe sleep with Bmo, and assessed the home, and sleeping area of infant.

S: TM works in Front sub, he was lifting pipes when he experiencing pain in his left wrist. Most pain wit extension of his wrist. 3 to 4/10. TM denies previous injury to his left wrist.

PHYSICAL EXAM: Examination shows comparing the right hand to the left, including the hand and wrist region, that there are skin scratches, very superficial, from activity. There is no tenderness. There is no soft tissue swelling. There is normal alignment. No deep tenderness to palpation over the fractures. No crepitus. No instability. Active range of motion is about 85% of the contralateral left side.

DOI: 5/4/2015. Patient is a 66-year old right hand dominant female credit collection clerk who alleges pain and swelling in the right hand, index finger and thumb due to everyday duties. Per OMNI, she was initially diagnosed with bi lateral hand tenosynovitis.

DOI: 4/17/2013. Patient is a 61-year old male senior quality assurance manager who sustained a work-related injury to his right hand from repetitive use of keyboard and mouse. As per OMNI entry, he was initially diagnosed with right thumb and wrist tendonitis. The patient is subsequently diagnosed with radial styloid tenosynovitis [de quervain]; periarthritis, unspecified wrist; osteophyte, unspecified elbow; and lesion of ulnar nerve, unspecified upper limb. As per progress report dated 6/29/16, the patient complains of pain at the cervical spine, right shoulder, right elbow, and right wrist/hand with stiffness, weakness and numbness. Physical examination revealed tenderness to palpation, spasms, and decrease range of motion, strength, and

O: A & O x3. No edema or redness noted at the contusion location, CN II- CN XII Grossly intact.

BB’s skin presents as pink, warm and dry. No obvious signs or symptoms of abnormal bruising or lesions present however, the patient states that the skin has of late has