Ms. Pletscher Case Interview

She was moved to the operating table using a pat slide board with the assistance of the surgical team using the correct manual handling procedure and moving aids. Her head was placed on a gel donut headrest, arm boards were put in place to support both her arms and she was covered with a warm blanket for warmth and privacy. The patient was in supine position lying on her back with her hands placed on the arm boards with the palms placed in anatomical position. The safety strap was positioned and secured just above her knees to prevent from falling, the arm boards were extended at ninety-degree angle to prevent hyperextension of the shoulder joint. All bony prominences were protected with padding to prevent tissue and nerve damage to the patient’s body.

CT scan of the cervical spine dated 01/07/14 revealed posterior fusion from C5 through C7. There is minimal anterior subluxation of C6 on C7.

MRI demonstrates severe narrowing of the right fouramen due to severe collapse at L5-S1. EMG demonstrates positive radiculopaty. The claimant has severe back and right leg pain. The claimant has a positive EMG. The claimant has an MRI which demonstrates up and down stenosis in the foramen at L5-S1, compressing the L5 nerve root due to severe collapse of the L5-S1 disk. The claimant has elected to proceed forward with an anterior interbody fusion at L5-S1 with an anterior decomprssion and stabilization. The claimant has severe collapse of the L5-S1 disk resulting in foraminal stenosis. The provider states a posterior decompression alone would be inadeqate given the severe collapse of the disk and the up and down

On 6/30/2015, client attended to her ILP meeting with her youngest son Keury. Child was well dress for the weather. Cm observed child very anxiety and he was telling client that he wanted to go to his unit because wanted to watch cartoon.

DOI: 9/18/2000. Patient is a 59-year-old female technician who sustained a work-related injury due to being jostled and jolted in the back of a golf cart which ran over a pothole. As per OMNI, she was diagnosed with post cervical protrusions, facet syndromes with headaches, lumbar facet syndrome and status post right shoulder repair/resection.

As you indicated, Dr. Scharf did find the applicant permanent and stationary. He noted a surgery to the applicant’s neck was recommended and authorized. However, the applicant decided not to go forward with the surgery, because he heard from his friend who had undergone a similar surgery in the past and did not have a positive result.

Dr. Abiera had reviewed a September 3, 2010 MRI of the cervical spine that revealed central protrusion/herniation at C3/C4, left paracentral protrusion/herniation at C7/T1, Disc bulges C4/C5, C5/C6 and C6/C7, left paracentral extrusion/herniation at T3/T4 and straightening of cervical lordosis. In addition, Dr. Abiera noted an August 11, 2010 x-ray of the cervical spine which revealed blastic lesions, incidental Clay Shovelers Fractures of C7 and an August 11, 2110 x-ray of the thoracic spine which was

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.

On 2/21/17 I went to the office of Neurosurgeon Dr. Schell. Ms. Ostrander had arrived and left before I arrived. Dr. Schell will not speak with case managers. I called Ms. Ostrander. She said Dr. Schell looked at the MRI disc and told her the compression fractures to her Thoracic spine had not healed and she needs a vertebral plasty done. This is going to be scheduled. He also told her that she has compression issues in her cervical spine but he would deal with this after the thoracic spine is taken care of. Dr. Schell’s office is supposed to schedule the surgery. The MRI done on 2/16/17 with and without contrast showed that the mild compression fractures at the anterior superior endplates of T5, T6, T7, and T9 are healed.

She said, she fell last night while playing volley ball. She landed on her right shoulder and heard a pop sound, too. She did not take any pain medicines. She applied icepack and felt burning pain. This was an interesting musculoskeletal assessment case. We assessed her right shoulder and compared with the left one. We found slight dislocation of the shoulder joint. She had good circulation in her right arm, no swelling noted in the right hand and the capillary refill was < 2 secs. Mary said, since she had burning pain, it could be a nerve injury, too. We also noted a slight swelling of her trapezius muscle on the right side. She complained of pain on palpation. Mary applied a sling to her right arm to keep it elevated. She may need an MRI to see the damage. Mary sent her to the urgent care. She told her that, since she heard the popped sound, the ER or Urgent care doctor can replace it. It will be a painful procedure, and she will need a strong pain medicine. She gave her the note for her teacher and asked her friend to drive her to the urgent

I interview Mrs. Bliden. My 1 is What was different in your life? No, they there was nothing different In their family. The 2 is Did you know anyone that served, who? Yes her husband Brother. I thought there will be all more people she knows. The 3 is How old were you? She was 10 I thought she will be younger like 7 or 6. The 4 is How did the war affect/impact you?

Alex grew up mostly in Olathe, Kansas after his family moved from California when his dad took a job at the Federal Aviation Administration as an air traffic controller. He graduated from Olathe Northwest High School. He went on to play baseball at Mid-America Nazarene University. After one year of college, he decided to enlist in the United States Army.

On 4/25/17 I met Mr. Westenberg for his pr-operative teaching at the office of Dr. Cherwin. He was given a refill on his pain medication. He will be having blood work done on 4/26/17. Mr. Westenberg has been instructed on the use of the sling and what home exercises he needs to do after surgery. He asked about returning to work in 5 to 10 days. He was told that Dr. Cherwin will give him a work slip stating no use of the left arm. The post operative appointment will be 10 days after surgery. He will be given the date and time the day of his surgery.

I s/w Dr.Kim he will see pt at rad dept pt is there now for Paracentesis he is waiting for a room s/w nurse at PIH she will contact Dr.Kim once Pt is in a room. Also I s/w sister Teresa whom stated pt has been declining for the past week c/o confusion, nausea, loa, abd pain also states patient is on lactulose.

On 9/20/17 Rebecca Berner met Ms. Johnson at the office of Dr. Linehan. I had a schedule conflict. Ms. Johnson arrived ambulating with a cane. She reports that her shoulder pain has improved since the cortisone injection. Her range of motion to the shoulder was about 130 degree. Dr. Linehan felt she could get more range of motion with continued daily stretching. She has been given handouts several times. Ms. Johnso reports she has continued pain and the right knee will give out at the time. Dr. Linehan said it was more related to arthritis.