Summary Of Dr. Tenut's Case Study

Based on the progress report dated 03/28/16 by Dr. Bakhos, the patient presents for follow-up of his right knee

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,

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

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

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.

Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last

Health History: A 25-year-old male injured his left knee in a recent skiing accident. The patient stated that he lost his balance because the inner edge of his right ski got caught while skiing. This resulted in the right leg being externally rotated followed by and audible “pop” as he lost footing. By evening, the right knee joint had become swollen, causing intense pain. The primary care physician referred the case to an orthopedist.

Per the panel QME on 12/29/15 by Dr. Matan, it was noted that the IW will need continuing medical care for the remainder of his life. Recommendation was made to see Dr. Lee for discussion of additional surgery. It was noted that the IW continues to take Dilaudid 16 mg per day which is a heavy dose. He opined that by this time, the IW is addicted to this medication. In

On physical examination of the right knee, the patient is tender at the joint line and lateral meniscus.

Based on the medical report dated 01/20/16, the patient reports that his low back pain is rated as 9/10 into the right lower extremity. It’s experienced between 76% and all of the time he is awake. Some of the patient’s daily activities are being prevented by this symptom. He reports numbness and tingling in his right lower extremity.

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.

Per occupational therapy (OT) progress note dated 01/26/16, the IW reported that his left wrist is less stiff and sore. Swelling is decreased at the wound site. Good composite fist is noted. Full tight composite fist is almost achieved.

The patient has difficulties ambulating stairs. Her pain is waking her up at night. She failed to improve with the plethora of conservative treatment entailing physical and acupuncture therapies, activity modifications, home-type exercise, injections, medications. On physical examination, the patient is utterly uncomfortable. She ambulates with antalgic gait. Well healed incisions are noted on the left knee. Patellar crepitus noted on the flexion and extension of the right knee with medial and lateral joint line tenderness more so in the medial side. McMurray's test is positive medially. Patellar crepitus is noted together with pain in patellar compression. Patient’s Voltaren gel was refilled. Patient was recommended to undergo right knee arthroscopy with partial meniscectomy and lateral patellar release surgery. She failed to improve with above mentioned conservative treatment. Any further conservative treatment will be of no benefit. Patient was also recommended 12 PT sessions for the right knee

DOI: 3/12/2013. Patient is a 57-year-old male service technician who sustained injury when he slipped and fell in mud while delivering a propane gas. Per OMNI, he is status post right knee surgery on 05/12/14.

Health History: A 25-year-old male injured his left knee in a recent skiing accident. The patient stated that he lost his balance because the inner edge of his right ski got caught while skiing. This resulted in the right leg being externally rotated followed by and audible “pop” as he lost footing. By evening, the right knee joint had become swollen, causing intense pain. The primary care physician referred the case to an orthopedist.