Pere Omnal Case Studies

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

She reports tenderness to the posterior aspect of the cervical spine, trapezius region and scapular region with deep palpation.

DOI: 06/04/2008. The patient is a 61-year-old female dispatcher who sustained a work-related injury to her right hand and arm due to repetitive duties. As per OMNI entry, she is status post right proximal median nerve decompression on 05/12/11 and right carpal tunnel release on 09/26/11.

Patient is diagnosed with bilateral carpal tunnel syndrome, bilateral elbow pain, lesion of the ulnar nerve of the bilateral upper limb.

There is tenderness with motion of the wrist. Strength is 4/5. She is tender over the first dorsal extensor compartment and has a positive Finkelstein’s test. Assessment includes internal derangement of the right wrist, status post right wrist arthroscopy and De Quervain’s tendinitis of the right wrist/thumb. Patient will benefit from an additional course of PT to enhance and restore strength and function of her right wrist. She will benefit from a thumb spica splint to allow her tendinitis to resolve. She will continue applying her Voltaren gel.

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

Per medical report dated 10/26/15 by Dr. Parsioon, the patient was initially seen on 9/14/15 for evaluation and treatment of cervical pain. At that time, he had neck pain without radiculopathy and bilateral hand tingling. IW stated that physical therapy made his neck pain increase and he wanted to make sure that it is okay to continue this. His chief complaint is pain in his neck radiating to the right shoulder and arm. He states the only time he gets the tingling sensation in the hand is

Based on the medical report dated 03/31/16 by Dr. Schonwald, the patient reports pain in his low back, left lower extremity, right lower extremity, as well as in his left hand that originates at his left elbow and to his fingertips.

Based on the latest medical report dated 02/10/16, the patient has undergone extensive PT. She was diagnosed with sprain/strain derangement of the cervical spine, cervical subluxation complex, and cervical brachial radiculopathy, sprain/strain derangement of the lumbar spine, lumbar subluxation complex and lumbar radiculopathy.

12/16/15 Progress Report indicated that the patient wakes up with headaches. She mentioned headache in the frontal vertex or temporal occipital areas. She also feels imbalance. She denies bruxism and has no significant neck symptoms. She reported having some minor neck tightness. She was being treated with acupuncture 2 X per week and craniosacral therapy 2 X per week. She noted that she was able to read better in the past two weeks. She had difficulty scanning a written page in the past. She also mentioned that her insomnia has slightly improved since initiating these 2 therapies. Physical exam showed no palpable spasms in her cervical region over her muscles of mastication. Cervical range of motion: backward flexion 70 degrees and forward flexion 60 degrees. She was able to turn 60 degrees to each side. She is able to tilt 40 degrees to other side. Comments: Based on the absence of objective findings, she has reached a medical end result with no need for any further treatment. No additional treatment or diagnostic testing is

DOI: 4/3/2009. This is 50-year-old male porter/cleaner who sustained injury to his left knee and shoulder while he was walking down the lobby when he tripped and fell over the masononite. Per OMNI, he underwent a shoulder surgery in 09/09, left total knee replacement in 08/24/10 and right ankle surgery in 08/28/13.

Per medical report dated 09/01/2015, the patient presents low back and right hip pain. She rates the pain as 8/10 and characterized as sharp and stabbing. The pain radiates to the right hip, right thigh, knee, leg, calf, right ankle, and foot and is described to be severe and constant. Her condition is associated with joint stiffness, tingling and weakness. Additionally, the pain is aggravated by any activity or movement, doing excessive work, and prolonged sitting. Relieving factors include application

Based on the medical report dated 06/27/16, the patient developed bilateral carpal tunnel syndrome over the past year and also some left lateral elbow soreness. Symptoms have progressed. She continues to perform regular work; some adjustments have been made to her work site and she takes short breaks. She takes ibuprofen tablets as needed. Her symptoms wake her from sleep despite night splinting. Of note, electrodiagnostic testing was consistent with moderate to severe bilateral carpal tunnel syndrome. The right side is equal

DOI: 12/1/2003. The patient is a 58-year-old female book keeper who is experiencing pain in her right arm and wrist due to performing her usual and customary job duties. Per OMNI, the patient is diagnosed with neck pain and bilateral upper extremity pain. The patient is subsequently diagnosed with lateral epicondylitis, right elbow; lateral epicondylitis, left elbow; radial styloid tenosynovitis; and enthesopathy, unspecified. As per medical report dated 6/23/16, the patient walks in due to worsening of symptom. She has worsening pain in the right upper arm, forearm, medial, and lateral elbows, and left upper arm, forearm, medial, and lateral elbow, right more than left. Pain is burning in nature and constant. Any gripping/grasping activity

At today's visit she is found in her room sitting in her recliner. She reports chronic, intermittent, dull, achy, lower back pain. Her current pain regimen is effective for her pain according to the facility staff. The staff reports that the patient is sleeping more hours during the day. She has increased generalized weakness. No acute distress noted this visit.