Work Related Injury Case Summary

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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.

Based on the medical report dated 03/29/16 by Dr. Riley, the patient complains of increased pain to both heels, left greater than the right. She states that the pain is most severe with the 1st step in the morning or after periods of rest. She is requesting new custom orthotics, as her existing pair have become very worn. They are more than 2 years old. Additionally, she sustained a trip and fall Injury on 2/2 with her knee "giving out." Two days prior to this visit, patient is with pain and swelling to the left great toe joint. She is unclear if the injury occurred with the fall, or in the process of …show more content…

There is a soft tissue mass to the left lateral ankle overlying the sinus tarsi, consider with lipoma.

There is collapse of the medial arch with calcaneal valgus with weight bearing. The IW functions in end range pronation throughout midstance of gait. There is tenderness upon palpation to the posterior plantar aspect of the left heel at the insertion of the calcaneus. There is mild pain with deep palpation to the right foot in the same location. She has pain with dorsiflexion and plantar flexion of the dorsal aspect of the left 1st metatarsophalangeal joint. There is no pain with active dorsiflexion and plantar flexion with resistance.
Current medications include Tylenol #3, Voltaren, Norco and Zoloft.
Of note, anteroposterior and lateral views of the left foot taken on this visit reveal no evidence of fracture or dislocation. There is mild periarticular osteophyte formation, however, no Joint space narrowing is noted.
Assessments are 1st metatarsophalangeal left foot joint sprain, plantar fasciitis, left greater than the right and symptomatic lipoma of the left

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