Multilevalgia Rheumatica Case Study

DOI: 02/27/2014. The patient is a 63-year-old male driver who sustained lower back injury while unloading foods and fell between the loading dock and rear trailer.

On examination of the back, there is slight to moderate pain to palpation of the right paraspinous muscles of the low back. Palpation reveals equivocal muscular spasm. The bilateral patellar and ankle reflexes are 0+.

Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.

On examination of the lumbar spine, there is tenderness and guarding of the paraspinal musculature. Range of motion is decreased secondary to pain.

DOI: 07/10/2012. Patient is a 67-year-old female licensed vocational nurse who sustained work-related injury to multiple body parts when she tripped over a cord and fell onto the floor while leaving a patient’s room. Per OMNI entry, patient is status post right total knee replacement on 1/10/2015.

Based on the progress report dated 02/29/16, the patient is doing well but reports intermittent pain. He has had a lumbar ESI on 06/15 with no relief.

DOI: 7/2/2010. The patient is a 57-year-old female claims examiner who sustained work-related injuries to her bilateral knees, low back, psyche, cervical, shoulder and left hip while packing contents of desk.

MRI of the lumbar spine was obtained on 05/22/14 which revealed status post posterior surgical fusion of L4, L5 and S1 with no evidence of recurrent/residual disc herniation. There is a mild disc bulge at T11-12, L2-3 and L3-4 levels.

DOI: 8/10/2016. Patient is a 38-year-old female retail specialist who sustained a work-related injury to her back when she was moving boxes.

DOI: 3/2/2016. Patient is a - year old female who sustained a work related injury when she tripped/fell backwards on to a pallet. As per medical report dated 5/2/16, it was noted that the patient had a trigger point injection last time, which relieved some of the tightness that she had in the low back. Pain is exacerbated with bending and extension activities. Pain level is 8. Lumbar spine examination revealed that there is 50% of normal range of motion with 80 degrees of flexion, 20-30 degrees of extension, 35 degrees of lateral bending, and 45 degrees of lateral rotation. Positive facet maneuvers, mostly on the right side is noted. Impression includes lumbar disc protrusion at L3-L4 and L5-S1 and facet hypertrophy at L3-L4 and L5-S1. It was

DOI: 1/12/2004. Patient is a 57-year old male hospital employee who sustained a low back injury due to moving a stack of medical charts.

DOI: 10/14/2009. Patient is a 44-year-old female hospital medical records clerk who sustained a work-related injury after tripping over garbage can and fell on her right knee on 02/07/2010.

DOI: 4/12/2014. Patient is a 53-year-old female sales advisor who sustained injuries to her right shoulder/upper extremity, thoracic spine and lower back when she lost balance and fell while pulling a cooler away from cart.

DOI: 12/29/2015. Patient is a 38-year-old male customer engineer who sustained injury when he stepped out of the car and slipped. As per OMNI notes, the patient sustained strain to the lower back.

Based on the progress report dated 11/18/16, the patient presents with chronic neck and upper back pain. Patient reports persistent neck pain and stiffness.