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Summary Of Work-Related Injury

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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

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