Work-Related Injury: A Case Report

He was given a prescription for Fexmid (cyclobenzaprine hydrochloride) 7.6 mg #90 1 tablet every 8 hours as needed to reduce muscle spasms, Voltaren XR (diclofenac sodium XR) 100 mg 1 tablet #60 1 tablet twice daily as needed for inflammation, and topical creams.

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

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

DOI: 9/30/1997. The patient is a 50-year-old female reservation clerk who sustained a work-related injury to her back and bilateral lower extremities when she tripped and fell.

Conservative treatment notes included aquatic physical therapy, acupuncture, narcotic pain medications, Transcutaneous electrical nerve stimulation (TENS or TNS), psychologist, and hypnosis. The patient also has tried and failed multiple over-the counter and prescription remedies for her opioid induced constipation including diet modification, stool softeners, and laxatives including Miralax, Senokot, Metamucil. Ducalax. It was noted that Movantik is being provided to help her with this situation. As per interval changes, the patient complains of ongoing neck and left upper extremity pain, and an increase in low back and left lower extremity pain. Patient states that she fell at home 2 weeks ago. She states that she injured her right arm and it has been swollen for 2 weeks. The pain score is 10 without medications and 2 with medications. The medications prescribed are keeping the patient functional, allowing for increased mobility, and tolerance of activities of daily living, and home exercises. Current medications incldue Nucynta, Percocet, Restoril as necessary for insomnia, Cymbalta, Neurontin, Cselebrex, Robaxin, Prilosec, Singulair, Vagifem, and

Post injection, he states he had 95% improvement temporarily for several days, but since then his pain to his lumbar spine has returned.

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.

On admission, Ms. Kelly complained of low back pain ranging in intensity from 7 to 8, out of 10, on the pain scale where 0 is no pain and 10 is the worst imaginable pain. She subjectively describes this pain as throbbing, stabbing, burning and radiating down into both legs, left worse than right. In addition, she has sharp, stabbing, burning pain in both her arms, left worse than right, and experiences intermittent tingling and numbness sensations in both her hands. She has pain in her neck and shoulder that she defines as tension-type pain. Factors that can aggravate the pain include

Based on the progress report dated 03/01/16 by Dr. Ahmed, the patient continues to complain of constant lower back pain radiating to her left leg which she describes as sharp with pins, and needles and intermittent numbness and weakness.

Objective Functional Improvement shows that the patient is now able to get dressed with minimum assist. He is also now able to navigate 2 flights of stairs without pain, same as prior, now able to walk for 8 minutes, same as prior, can now lift 6.5 lbs. of weight, improved from prior, and push 6 lbs. of weight, same as prior. Therapy goals for this patient in the next 4 weeks are to reduce inflammation from moderate to minimal and increase cervical and lumbar spine flexion and bilateral rotation by 3 degrees. The patient in the next 4 weeks will be able to get dressed easier, navigate 2.5 flights of stairs without pain, walk 9 minutes from 8 minutes, lift 7 lbs. of weight, and push 7 lbs. of

As per medical report dated 3/10/2016, patient complains of low back pain rated at 7/10 with left lower

Based on the progress report dated 04/05/16 by Dr. Fieser, the patient complains of pain in the left knee, left ankle and left foot, associated with numbness and tingling in the left leg/foot, as well as weakness in the left leg. He describes the pain as sharp, cutting, throbbing, dull, aching, pressure-like, cramping, shooting and shocking with muscle pain and pins-and-needles sensation.

Based on the medical report dated 12/16/15, the patient follows up from completion of PT. She has had a left sacroiliac (SI) joint and piriformis trigger point injections which have provided some relief. She states that PT did help somewhat but there is increase of pain with doing the exercises. She states she also

Mr. Valentine is a 34-year-old patient who is seen at the medical clinic today in regard of follow up with his chronic care of his left hip pain. Patient reports that he had a gunshot wound on the right hip and because of that he will compensate all of his body weight or pressure, so then his left side accommodate by dominant for the right side hip. Patient's stated over time of doing that he developed chronic left hip pain. Patient has narrowing or arthritis on his left hip; otherwise, he also is taking Indocin 50 mg three times daily with food and he also has Keppra 1000 mg twice daily. He took all of his medication as directed and he is doing well to control his left hip pain. He stated