Patient Analysis: A Case Study

Williams, the patient reports occasional low back pain that he rates from 0-3/10. On this visit, he has no low back pain.

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,

Physical therapy saw the patient, and the result of the examination are as follows; 6/10 left knee pain at rest and during activity (0 no pain, 10 worst pain), manual muscle testing for both upper and lower extremities were 4/5 except left knee flexion/extension 3+/5 due to pain, sensation on both UE/LE were intact to light touch, Stephen requires a moderate assistance of one person for both functional mobility and gait activity. He uses a front wheeled walker up to 35 feet due to decreased balance and antalgic gait from the left knee

DOI: 10/3/2013. Patient is a 51-year-old male bottling machine operator who sustained injury to his left knee when he hit it on an L-bracket after he stepped over a conveyor belt, missed a stool, and fell over. The patient underwent a left knee arthroscopy on 3/31/14.

DOI: 4/01/2015. The patient is a 53-year-old-male old carpenter /foreman who sustained a work- related injury while lifting a high beam when the beam slipped before being placed into the ground pushing him between the beam and leads, crushing his right ankle and foot.

The patient stated that overall the symptoms have decreased. Antalgic gait has improved. The pain is decreased but it increases in the morning. The patient reported pain 3/10-scale level. Rom and Muscle strength remained the same. Swelling has decreased. Tenderness to palpation in the lateral and medial malleolus decreased. Muscle testing plantar flexion remains weak. Dorsiflexion remains weak. Review of Systems revealed joint swelling and loss of bladder/bowel control. Treatment plan included PT

Based on the progress report dated 08/26/16 by Dr. Boparai, the patient presents for left foot pain, rated as 2.5/10 with medications and 10/10 without medications. Quality of sleep is good. Activity level has remained the same. Patient is going to hyperbaric oxygen treatment daily and wound care clinic weekly for left foot amputation due to frost bite/gangrene.

As per office notes dated 5/4/16, the patient is seen for bilateral elbow pain and bilateral wrist pain. She rates the pain as 3/10 with medication and 7/10 without medication. She is active for at least six hours a day and has energy to make plans. Her activity level has

The medical evidence shows the claimant had twisting injury to left knee with lateral meniscus tear on 7/1/13. He was also noted to have preexisting osteoarthritis of the left knee. The claimant underwent arthrosopic partial meniscectomy on the left knee on 2/27/14 with some symptomatic relief. An orthopedic report on 1/13/14 noted ongoing left knee pain. The physical exam showed tenderness; pain with flexion and extension; positive McMuray's test and negative Drawer's test. X-rays of left knee on 1/13/15 showed mild left knee osteoarthritis.

At today’s visit she is found sitting in her room in her wheelchair. She is awake, alert and oriented. She reports that she has had multiple falls over the weekend. She denies pain, shortness of breath and chest pain. The facility staff reports that she has had multiple falls and seems to be falling more lately. The patient uses a wheelchair;

DOI: 3/14/2014. Patient is a 57-year-old female lead operator who sustained a work-related injury when she twisted her right knee as she stepped down off a chase cart. As per OMNI, the patient was diagnosed with chronic right knee pain status post anterior cruciate ligament repair, and significant degenerative joint disease of the knee. She is s status post right knee anterior cruciate ligament (ACL) reconstruction on 07/15/14.

Patient reports back pain that radiats down to her legs, denies injury to the site. current pain 4/10. Patient also reports bilateral knee joint pain. Patient denies chest pain, SOB, N/V/ D, or fever.

DOI: 2/10/2011. Patient is a 56-year-old male controller who sustained a knee injury when he hit his knee when he turned while sitting on a chair. Per operative reports, the patient is status post right knee diagnostic arthroscopy with chondroplasty and removal of scar tissue on 12/14/2012, right knee arthroscopy and trochlear microfracture, partial medial meniscectomy and plica excision on 02/28/2012, and right total knee arthroplasty on 11/30/15.

Activity limitations for the patient are ambulation and general mobility. As we can see from the table, her lack of upper extremity range of motion has disallowed her to perform overhead activities. Her lower extremity neuropathy accompanied by decreased arthrokinematic mobility and weakness has severely decreased her ability to ambulate. These activity limitations lead to various participation restrictions including; inability to stand for prolonged periods of time, a requirement for her job, and, inability to participate in her usual leisure activities such as dancing and nature walking.

The Patient was awake, alert, oriented times 4 (to person, place, time, and situation), no acute distress, and denied any allergies. During this assessment the patient was position in sitting position, and the patient was inspected from head to toe, and the skin was normal, warm, dry, intact, and within ethnicity. The hair groomed within the age appropriate and not greasy. The head was normocephalic and atraumatic. During the skull palpation, patient denies any pain, any no lesions noted. The patient had the eye’s glasses on, and the vision was 20/20. The pupils were equal, round and reactive to light. The patient extraocular movements were intact, and normal conjunctiva noted. The patient ears, nose, mouth, and throat were all in normal states.