Pelvis is stable. The patient is ambulatory and show no restrictions in motion at the hip, knee, ankle, or foot. Examination of the left upper extremity shows a posterior splint. This is removed and shows some mild swelling and ecchymoses in and around the posterior aspect of the elbow and ulnar forearm. Axillary, radial, median, and ulnar nerves are intact to motor and sensory tone.…
On 12-30-15, PT Wilcox documented that Mr. Durland reported he had increased soreness since the last visit with increasing symptoms down his right posterior/medial thigh. Mr. Durland was scheduled to see Dr. Hagood on the same day and Dr. Hagood was going to check his prostate for enlargement. PT Wilcox documented STR in prone along right sacral angle, along right ST (sacrotuberous) ligament to ischial tuberosity, TTP (tender to palpation) over medial edge or ischial tub and OI (obturator…
Crepitus is noted. There is tenderness of the patella tendon, distal half of the…
Patient reports 2/10 pain with medications, and 8/10 without. Patient is not attending any therapy this time. On examination, there is tenderness at the right index metacarpophalangeal (MCP) joint with full range of motion,…
On examination of the lumbar spine, the paraspinal muscles are tender upon palpation, bilaterally from L4-S1, worse at the L5 level. There is radicular pain into the right leg. Careful palpation reveals muscle spasms with associated trigger points in the bilateral lumbar paraspinal muscles. There is restriction of movement due to pain and stiffness. Straight leg raise is positive on the right at 30 degrees.…
DOI: 11/1/2000. The patient is a 60-year-old male sales representative who sustained injury while he was grabbing a ladder to get samples and felt pain in his back. Patient is status post L5-S1 intradiscal electrothermal therapy procedure and L5-S1 fusion on 04/30/13. Urine drug screen obtained on 03/16/15 showed positive for hydrocodone, hydromorphone, dihydrocodeine, norhydrocodone, carisoprodol and meprobamate.…
Per the panel QME Supplemental report dated 12/31/15, the patient is not yet at maximum medical improvement (MMI). Patient was diagnosed with right knee sprain with chondromalacia/osteoarthritis. As per medical report dated 8/24/16, patient complains constant bilateral knee pain, right greater than left, rated 8/10,…
On examination, there is tenderness over the lumbar paraspinals. There is pain with lumbar flexion and extension. Sensation is diminished to light touch over the left L5 and S1 dermatomes. Patient was diagnosed with status post bilateral L3-5 decompressive laminotomy and lumbar radiculitis versus radiculopathy.…
This is a 45-year-old male with a 2-20-2015 date of injury. A specific mechanism of injury has not been described. DIAGNOSIS: Sprain of joints and ligaments of unspecified parts of neck, initial encounter 01/11/16 Progress Report describes that 15 minutes were spent in review of the results from the urinary drug screen, which was administered at the previous visit and deciding whether any modifications are appropriate to the treatment regimen. The pain is better and down to a 3/10. The neck pain remained mild.…
DOI: 10/20/2009. Patient is a 43-year-old male maintenance technician who sustained injury after lifting a manhole. Per OMNI entry, he is status post lumbar discectomy and foraminotomy on 01/25/2010 and repeat L5-S1 discectomy and foraminotomy on 02/28/2013. Based on the latest medical report dated 11/03/16 by Dr. Wensel, the patient presents with intermittent shooting left leg pain that occurs several times a week.…
DOI: 9/20/2015. Patient is a 32-year-old female certified nursing assistant who sustained a work-related injury when she felt pain in her left knee while transferring a patient. Per the medical report dated 03/23/16, the patient presented with low back and left leg pain, lumbar paravertebral muscle spasms and medial thigh pain. He has been refractory to 12 PT visits.…
DOI: 12/1/2014.Patient is a 52 year-old female sales advisor who sustained injury when she slipped on a wet floor landing on her right side. Per OMNI, patient was diagnosed with closed fracture of the right radius, back contusion, right hip contusion, right elbow contusion, right shoulder sprain, right elbow sprain, cervical strain, and right shoulder contusion. The patient was subsequently diagnosed with unspecified injury of muscles and tendon of the rotator cuff of right shoulder-sequela. Per Doctor’s First Report of Occupational Injury dated 4/9/2016, patient has been experiencing pain in the right wrist, arm, lower back and neck. She states she fractured her right wrist and was given a wrist splint.…
DOI: 3/11/2011. Patient is a 46-year-old male stationary engineer who sustained a work-related injury when he fell from a ladder onto his right side while fixing a valve. He is status post right knee arthroscopy on 10/8/12, status post right foot fusion surgery on 9/25/13 and hardware removal surgery on 5/28/14, and status post right shoulder surgery on 12/12/11. Based on visit note dated 06/23/15, the patient presents for follow-up of neck, upper extremity, right hip, right shoulder, bilateral knee, back, and right foot pain.…
Hip bursitis is a common problem in athletes. It causes pain in the hip and on the outside of the upper thigh. The bursa is a sac filled with fluid that allows a joint in the body to move smoothly. If the bursa becomes inflamed it can be very painful for a person when moving the joint. Athletes who participate in sports that involve a lot of movement and running normally can see this injury as a result.…
DOI: 5/28/2012. Patient is a 64-year-old female home attendant who sustained injury when a client put her motorized wheelchair in reverse and it ran over her right foot, pushing her up against the wall. Per OMNI, she underwent a right knee arthroscopy with partial medial and lateral meniscectomy, chondroplasty, synovectomy and joint debridement on 03/18/13. Based on the progress report dated 03/03/16, the patient is currently on PT 1-2 times per week.…