DOI: 9/4/2014. The patient is a 51-year old male paint maker who sustained a work-related injury when he missed a step on a platform and fell, jarring his back. As per OMNI entry, he was diagnosed with lumbar sprain and lumbosacral disc degeneration. 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. The patient was found to be an excellent candidate for the Health Education for Living with Pain (HELP) functional restoration program and successfully completed the program on 12/23/15. The patient was 100% engaged throughout his program. On his arrival to the program, …show more content…
Sensation is decreased to light touch, pin prick and temperature on the S1 distribution of his left lower extremity. Motor examination reveals 4/5 with left hip flexors/extensors/ abductors/adductors and knee extensors/flexors, 4-/5 with left ankle dorsiflexors and plantar flexors and 3+/5 with left external hallucis longus (EHL). Mood is dysthymic. Insight is improved with regard to his pain and fear avoidant behavior. Current medications include hydrocodone/APAP, trazodone, Lyrica, Lidoderm patches and orphenadrine. Diagnoses include chronic low back pain; left lower extremity radiculopathy; bilateral lumbar myofascial pain syndrome; sleep disorder; pain disorder; major depressive disorder; and history of methamphetamine abuse and addiction. It was noted that the patient has made significant gains in the HELP functional restoration program attaining his goals. He is still unable to return to work but is determined to do so. He is certainly not regressed in any way. He continues in a positive direction in his home exercise program despite occasional flares. He has made some medication reductions since he has left the
groups of her lower extremities bilaterally. Sensory exam is normal to pin prick and light touch
As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his
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
Electrodiagnostic consultation report dated 10/02/15 revealed normal study of both upper limbs and cervical paraspinals. No evidence of cervical radiculopathy. No median or ulnar neuropathy.
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.
AME dated 6/19/2012 future medicals recommends access to follow up visits for monitoring of his condition with continued provision of pharmacologic agents as prescribed by the managed by the designated primary treating physician. In the setting of symptom flare-ups, re-instatement of brief courses of traditional physical therapy/chiropractic treatment/acupuncture/massage therapy would be beneficial in restoring to baseline function, not anticipated to exceed the requirement of 10 to 14 sessions of all modalities combined per calendar year. Yearly
MD discussed with Dr. Kinsman the following: Assessment (1) The patient is somatically oriented; (2) The patient is getting some improvement regarding activity level and endurance/ergonomics with the current court of physical therapy, but the patient has very little understanding of functional management as a long-term strategy to manage her symptoms; (3) MD and Dr. Kinsman feel that the patient would likely be a good fit for the functional restoration program and deserves a one day evaluation for the functional restoration program.
Based on the progress report dated 03/28/16, the patient complains of pain to his lumbar
DOI: 12/15/2015. Patient is a 43-year-old male senior buyer who reported pain in his left elbow/arm from repetitive motion using the keyboard. Per OMNI, he was initially diagnosed with left elbow epicondylitis.
Based on the medical report dated 03/30/16, the patient has had pain in the right lower leg, numbness and tingling on the left side as well, rated as 8-9/10.
He complains of constant left elbow and wrist pain, which radiates from the left elbow to the finger tips with numbness. Pain is rated as 5/10. He takes ibuprofen 800mg with some relief. He reports intermittent numbness into
Sensation is reduced to light touch over the radial aspect of the forearm and hand. Impression includes the following: right wrist sprain/strain injury, rule out triangular fibrocartilage tear; right de Quervain’s tenosynovitis; right lateral epicondylitis; right shoulder and cervical spine sprain/strain and myofasciitis; history of diabetes mellitus and hypertension; and heartburn and reflux with history of nonsteroidal anti-inflammatory medication use and controlled on proton pump inhibitor.
After the first week of admission, Mr. Wilson’s depressive symptoms did not improve. He was observed to stay in the bedroom most of time and lack of motivation to care for
Per the medical report dated 05/27/16 by Dr. Joshi, the patient continues toward goals. Patient reports that PT alleviates her pain, improves overall functional limitations, allows her to perform activities of daily living (ADLs) with less difficulty and allows her to take care of infant child without assistance or difficulty.
DOI: 11/14/2005. Patient is an 83 year old female demonstrator who sustained injury to her lower back while breaking down on her table.