Summary Of Chronic Injury: A Case Study

02/12/16 Progress Report noted tat the patient is s/p left calcaneus fixation on 09/24/15. His current pain level ranges from 3/10 to 7/10 with standing up. There is sharp pain with stiffness and welling. Medication: Albuterol and Symbicort. Assessment/Plan: Gastrocnemius equinus, left and post-traumatic arthritis of the left lower leg. Surgery paperwork complete and the patient will follow-up after the surgery.

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,

Based on the progress report dated 08/23/16, the patient complains left knee pain upon walking. Discomfort was described as aching, tingling, intense, severe, continuous, pain, discomfort, increasing with movement and varying with activity. Pain is rated as 5/10 without medications and 4/10 with medications.

Assessments are 1st metatarsophalangeal left foot joint sprain, plantar fasciitis, left greater than the right and symptomatic lipoma of the left

Pain was rated 7/10 in severity. Physical examination revealed decreased lumbar range of motion in forward flexion due to pain. Gait was antalgic. She had difficulty with heel walk and toe walk. SLR was positive on the left. Motor exam revealed weakness 4/5 of the extensor hallucis longus and tibialis anterior muscles on the left. Reflex testing was normal. Sensory examination revealed hypoesthetic region over the left L5 distribution to pinprick and light touch. Current medications included Gabapentin, Tramadol, Methocarbamol, Cymbalta and Synthroid. Treatment plan discussed includes lumbar laminectomy, discectomy, foraminotomy and partial facetectomy at L4-5, preoperative medical clearance and post-operative bracing.

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

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

Per the IME report on 4/28/16 by Dr. Pierce Ferriter, the patient reports that he is actively treating with physical therapy and chiropractic treatment at a frequency of 3 to 4 times per week. The patient’s diagnoses include resolved lumbar strain, resolved cervical strain, resolved left shoulder strain and resolved right knee strain. There is no medical necessity for further physical therapy, orthopedic treatment of diagnostic testing based on examination.

MRI of the right shoulder report dated 03/04/14 revealed tear of the supraspinatus/infraspinatus tendon and subscapularis tendon. There is tendinosis of the teres minor. Abnormal signal is noted within the biceps tendon concerning for tear. Degenerative changes involving humeral head are seen. Bone marrow edema is noted involving the superior lateral aspect of the humeral head and the glenoid bone. Degenerative changes at the glenohumeral joint and the acromioclavicular joint are noted. There is edema and sclerosis of the posterior glenoid. Abnormal cortex of the posterior glenoid is demonstrated

DE Quervain’s Tenosynovitis. The rationale for choosing this condition as a differential diagnosis as the other is likely is based on the decreased sensation and the inability to grasp objects tightly. Evidence: De quervain’s tenosynovitis disease, also called gamer's thumb or mother's thumb, is a common pathological condition of the wrist. Even though the exact etiology is unknown, the cause of de quervain's disease is thought to be due to thickening of the synovial sheath containing the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons. This disease can cause irritation of the muscles, pain and swelling over the radial side of the wrist in patients along with an increased difficulty in gripping objects. Signs and symptoms of de quervain’s tenosynovitis include mild pain, limited ROM, swelling, and decreased sensation and locking with thumb motion (Patel, Tadisina, & Gonzalez,

Patient is unable to bear weight secondary to pain and swelling most prominently over the lateral malleolus, although the entire foot is somewhat swollen and hyperemic. He does have an ecchymotic area inferior to the lateral malleolus. Active range of motion. He is weak on dorsiflexion with adequate but somewhat diminished active range of motion on plantar flexion. He also demonstrates weakness on eversion and inversion although weaker with resisted inversion. On palpation, he is tender most prominently on the lateral aspect of the foot over the lateral malleolus not well localized with prominent tenderness over the ATFL and CFL, although

The claimant is a 27-year-old female who sustained an injury on 09/27/2017 when she fell on a wet floor causing a fracture in her right wrist.

MRI of the left ankle and foot obtained on 01/26/16 showed evidence of moderate to high-grade partial tear of the anterior talofibular ligament and moderate partial tear of the calcaneofibular ligament. There is evidence of mild partial tear of the deltoid ligament. Mild to moderate osseous contusion of the talar body is seen. There is a mild sinus tarsi edema. There is a minimal subtalar and tibiotalar effusions.

DOI: 11/27/2015 . Patient is a year old male employee who sustained injury due to lifting heavy items all day. Per OMNI, he was initially diagnosed with

Based on the latest medical report dated 11/23/15, the patient reports that his bilateral feet pain is over the ball of the foot. He has increased pain with the first step out of bed, right greater than the left. He has increased pain with pressure over the area. He also reports occasional numbness and tingling. There is pain with prolonged walking. Patient is going to PT. He is taking Advil occasionally.