Work Related Injury Case Summary

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.

01/14/16 Progress Report noted that the patient has severe and constant pain. It is associated with numbness, tenderness, and restricted motion. Current pain level is 8/10. The patient is here for injection to the left subtalar joint. The exam of the left ankle revealed intact skin. There was no erythema or abrasion. No signs of infection. NVI distally. Distal sensation intact and brisk capillary refill. Clinical Assessment: The patient would like to go ahead with the

Dr. Justin Clayton at the Mercy Clinic Orthopedic Surgery evaluated the claimant on April 6, 2018. Dr. Clayton stated the claimant may have rheumatoid disease and prescribe him Meloxicam. In addition, he reported the claimant would be referred for further arthritis evaluation (Ex. 23F).

Physical therapy saw the patient, and the result of the examination are as follows; 6/10 left knee pain at rest and during activity (0 no pain, 10 worst pain), manual muscle testing for both upper and lower extremities were 4/5 except left knee flexion/extension 3+/5 due to pain, sensation on both UE/LE were intact to light touch, Stephen requires a moderate assistance of one person for both functional mobility and gait activity. He uses a front wheeled walker up to 35 feet due to decreased balance and antalgic gait from the left knee

Medical Diagnosis: Client was diagnosed with a fractured right tibia bone, and fractured right radial bone. Client has diabetes mellitus type one. Client has history of hypertension and was admitted with chest pain following accident. The client fell off her bicycle while walking her dog.

Christina sent to physical therapy after acute injury two weeks ago. Reportedly slipped on a wet surface went airborne and landed violently on her buttock. I do not believe this was documented but this was what described to me. She notes prior to that she had no real history of any real back issues and was working in the maintenance job. Oddly, she was in the hospital back in early fall and they did a lumbar MRI which is fairly negative. I do not have the results in the chart at this point. Apparently, it was done because she said she had some leg tingling. I am not sure what to make of that. Regardless, she does not report a lot of history and had a high level of function. Stating she would like to work and be active. She states since his acute fall she has been fairly miserable. She notes intense right buttock and right leg numbness and pain. Pain can fluctuate from a 9/10 to a 0 depending on activity and position. Notes increased pain with Valsalva, coughing, or sneezing, but particularly Valsalva maneuvers. Most relief of pain is supine with the knees

HISTORY OF PRESENT ILLNESS: This patient is a 10-year-old male. He was in a Motocross accident this past Saturday, sustaining tibial eminence fracture, displaced. He presents today for evaluation.

Patient is unable to bear weight secondary to pain and swelling most prominently over the lateral malleolus, although the entire foot is somewhat swollen and hyperemic. He does have an ecchymotic area inferior to the lateral malleolus. Active range of motion. He is weak on dorsiflexion with adequate but somewhat diminished active range of motion on plantar flexion. He also demonstrates weakness on eversion and inversion although weaker with resisted inversion. On palpation, he is tender most prominently on the lateral aspect of the foot over the lateral malleolus not well localized with prominent tenderness over the ATFL and CFL, although

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.

DOI: 12/13/2012. Patient is a 64-year-old male security officer who sustained a work-related injury to the right knee when he missed a step and fell down the stairs. As per Omni, the patient had a right knee meniscus tear. The patient had right knee replacement on 11/19/14. Per QME Dr. Murphy on 08/11/15, the patient has a 20% whole person impairment rating. Future medical care includes 4-6 visits per year for recurrent symptoms, narcotic/nonsteroidal anti-inflammatory drugs (NSAIDS) in addition to gastrointestinal stabilizing medications, pain management specialist monitoring, office visit with an orthopedic surgeon once a year with X-ray, revision surgery in the future and bone scan.

DOI: 8/26/2007. Patient is a 46 year-old male general production worker who sustained a work-related injury to his left ankle as a result of walking over an uneven driveway. The patient was subsequently diagnosed with tendonitis and degenerative joint disease. As per SOAP notes dated 7/6/16, the patient complains of ankle pain and that he is out of medications. Objective findings reve3aled pain with motion and while in cast. It was further noted that it seems to cycle and stable. Motion in the “STJ” residual from failure of fusion pain producing relative to time on it, in cast/out. Plan notes that left ankle lateral aspect is the area of tenderness. Current medications are Norco and

DOI: 1/5/2012. Patient is a 55-year-old female home attendant who alleges injury to her lower back arising from employment. Per OMNI, she was initially diagnosed with low back pain. Patient is status post left-sided laminectomy with recess decompression at the L5-S1 level on 05/28/15.

DOI: 9/15/2008. Patient is a 63-year-old female home attendant who sustained injury while she was transferring a client from wheel chair to commode when she felt pain in her back. Per OMNI, she sustained strain to back and left wrist.

changes seen at the site of insertion of Achilles tendon. Edema is evident in the left

The ordered procedure for Ms. Smith was for a left ankle radiograph for three projections. The exam was completed in room five of the University of Virginia diagnostic radiology hallway. The views requested