Symptoms And Treatment Of Pain Essay

878 WordsDec 16, 20154 Pages
This is a 71-year-old female with a 2/29/2000 date of injury, when she slipped and fell because of oil on the ground. Diagnoses: Pain in thoracic spine; low back pain; traumatic arthropathy, unspecified site; unspecified sprain of unspecified wrist 12/01/15 Progress report describes that the claimant has increased right shoulder pain. The pain was previously well controlled with medications. The patient stated that she may not be able to drive to her appointments much longer given she also gets radiation. PE revealed normal gait. There was slight to moderate spasm over the lumbar spine R>L. AROM: flexion 70 %, extension 60 %, Right lateral flexion 70 % and Left lateral flexion 70 %. SLR is positive on the right. Slight spasm was noted over the cervical spine. AROM: flexion 80 %, extension 80 %, right lateral flexion 70 % and left lateral flexion 70 %. Spurling test is positive on the right. Shoulder exam revealed mild tenderness of the bicipital groove and AC region R>L. Impingement sign was positive. AROM: Right 120 degrees, flexion 140 degrees, extension 40 degrees and adduction 40 degrees. There was mild tenderness of the volar aspect of right wrist. ROM was normal. TInel and Phalen’s signs were negative. Treatment plan includes Tylenol, Soma, Prilosec/Omeprazole and continue home exercising and stretching. Follow up is in 2 months. 09/30/14 progress report states that the patient has a history of cervical spine discomfort at 3/10, right shoulder discomfort at 6/10

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