Patient Alsharafi Mariam Case Summary

left shoulder pain. She complains of shortness of breath and is very apprehensive about dying.

HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weighed approximately 40 pounds. Around the first of January this year she began to complain of back pain that

On Exam:  BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the

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.

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.

The patient is a 72 year old female. She has been experiencing progressively worse pain and stiffness in her joints. She is reports that she is having decreased range of motion, redness, and swelling in her joints. She is reports symptoms occur in the same joints on both sides of her body. She is also reporting the symptoms are worse when she first wakes up in the morning.

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

A review of her medical record indicates that she has a history of functional decline, dementia, weakness, MRSA, cognitive communication deficit, presence of right artificial hip joint and HTN.

Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is

Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications):Denies pain or stiffness in joints. Denies swelling, heat, or redness in her joints. Denies deformity of bones or joints. States no self or family history of arthritis. Complains of “achy fatigue” in lower legs at the end of the day. Uses a walker for increased stability. States she is “afraid of falling” so uses a walker at all times. States she fell in her kitchen late one night and bumped her head on the laundry room door. States she did not feel dizzy, just tripped over a kitchen chair with her walker. Called 911 for assistance but refused to go to the hospital for evaluation. Denies fractures or traumas to bones. States she has mild back pain when standing for prolonged periods of time. States she uses a shower chair to avoid fatigue in shower. States she bathes, grooms and dresses herself without assistance. Grandson assists with

The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.

Exam was 5/5 in the upper extremity and right lower extremity. She had 5-/5 of her left quadriceps. Tone was normal. Sensation was intact to primary modalities.

The x-rays of Plaintiff’s spine showed normal alignment, no swelling, no fracture or dislocation and normal lordosis of the cervical and lumbar spine. Plaintiff’s left knee x-ray also showed no fracture or dislocation, but moderate decrease in the meduial articular joint space. Plaintiff was given a general diagnosis of neck pain, back pain, low back pain and left knee pain. Plaintiff was prescribed 3 sessions per week for 6 weeks of physical therapy.

Musculoskeletal- erosive destructive changes in the elbows, wrist, and hands consistent with rheumatoid arthritis, has bilateral total knee replacements with stovepipe legs and perimalleolar pitting edema 1+. I feel no pluses distally in either leg.

Loss of movement, loss of sensation, including the ability to feel heat, cold and touch, loss of bowel or bladder control, exaggerated reflex activities or spasms, changes in sexual function, sexual sensitivity and fertility, pain or an intense stinging sensation caused by damage to the nerve fibers in spinal cord, difficulty breathing, coughing or clearing secretions from lungs.