DOI: 08/17/2010. The patient is a 55-year-old female assembly worker who incurred a work-related injury when she fell with her face forward after tripping on a curb. Per AME report dated 05/02/12 by Dr. Perelman, the IW is P & S 8-12 months post injury. Future medical care includes orthopedic evaluations, PT, chiropractic care, and acupuncture to the cervical spine. The patient underwent a cervical ESI at C5-6 per procedure report dated 02/10/12 with no benefit. Based on the initial pain medicine evaluation report dated 06/22/15, the patient complains of constant neck pain which radiates down to the bilateral upper extremity, fingers and hands. Pain is accompanied by intermittent tingling and numbness in the bilateral upper extremities to the level of the fingers and muscle weakness. The neck pain is associated with occipital, temporal and frontal headaches and muscle spasms in the neck area. The patient describes the pain as aching, burning, pins and needles, sharp, and stabbing. The pain is aggravated by activity, flexion/extension, prolonged sitting, pulling, pushing, repetitive head motions and standing. She also reports severe difficulty in sleep. …show more content…
Prior treatments are medications, PT, acupuncture and cervical ESI with limited benefit. The patient has a history of anxiety disorder, depression, diabetes, and hypertension, controlled with medications. On examination of the cervical spine, there is tenderness noted. Pain was significantly increased with flexion and extension. Sensation is decreased in the bilateral upper extremities. Strength is decreased in the bilateral upper extremities. She scored 64% on the Oswestry 2.0 disability index (ODI) and 74% with the Neck disability
Witvrouw, E., Mahieu, N., Roosen, P., & McNair, P. (2007). The role of stretching in tendon injuries. British journal of Sports Medicine , 224-226.
Shoulder and neck pain are the most common musculoskeletal disorders one can get. Right sided neck and shoulder pain is one that the assistant is highly prone to developing, and is difficult to avoid. Reason being is frequent reaching across the assistant’s mid-line with the right arm. Neck pain can also be caused by leaning forward with your head bent down for a long period of time.
L. H. a 22-year-old female who came into the clinic as a new patient complaining of lower back pain. Vital signs include: height 62 inches, weight 108 lbs., and 16 respirations. The patient stated that her back pain has gone on for quite sometime now (about 2 years total). She works as a nursing assistant in a nursing home in Wahoo. The physician stated that he wanted to taper her off tramadol (she takes 150 mg a day). He also wants to taper her off Effexor as well. The doctor noticed that the painful region was in the patient’s upper left side of her back. He recommended to the patient that L1 to L2 and L2 to L3 facets would benefit from steroid injections. The patient and her mother wanted to make sure they met their
During the review period, the claimant was diagnosed with cervical spine radiculopathy, pain in the right shoulder, a strain of the muscle, fascia, and tendon of the long head of the biceps, and right arm, and intervertebral disc degeneration of the lumbosacral spine.
An emergency department note dated 11/02/2017 indicated that the claimant presented with a low back pain and right hip pain. His back pain started a month ago and had been worse the past 2 weeks. He stated that pain is aggravated by sitting and slightly relieved by standing. His BMI was 31.92. A lumbar spine x-ray was ordered and medications were provided.
DOI: 09/14/2011. Patient is a 55-year-old female hospice licensed vocational nurse who sustained an injury when her car was struck by another car resulting in neck, upper/lower back, and left shoulder injuries. Patient is diagnosed with severe cervical degenerative disc disease, disc protrusions and stenosis of the cervical spine, and upper extremity radiculopathy. She is status post anterior cervical discectomy, partial corpectomy and fusion at C4 to C7 with placement of interbody cages and autologous iliac crest bone graft and anterior plating plus a posterior fusion from C4 to C7 in 02/08/2013.
his is a 36-year-old male with a 7/3/2015 date of injury, when a large pile of boxes containing Octopus weighing around 50 pounds each, fell on the patient.
Background/history: Margaret is a 38 year old woman who lives in Conway Massachusetts. Margaret’s primary disability includes ADHD and a Processing Disorder, which impacts her focus and concentration. She experiences a secondary disability of Fibromyalgia and Ehlers Danlos Syndrome. Margaret stated during the evaluation that she too suffers from PTSD, General Anxiety Disorder, Major Depression and a sleep disorder and is presently taking medication. She went on to say she has arthritis in both her hands and her shoulders pop out of socket easily.
Passive Range of motion (ROM) shows forward flexion and abduction to 160 degrees, and external and internal rotation to 40 degrees. Strength testing is 4/5. Impingement sign is positive. Hawkin’s and Neer’s tests are positive.
Review of claimant’s stated pain/limitations: He rates it as a 7 at best and up to a 10. Mr. Anderson said the pain interferes with all aspects of his life. It affects his sleep. Mr. Anderson said any activity increases back
Patient referred to physical therapy to evaluate diffuse upper back and neck pain. She was involved in a motor vehicle accident like three years ago and never had any post accident injuries. She notes mostly central _____ cervical and upper thoracic pain and occasional headaches that may or may not be cervically related. Denies any radicular symptoms. Seems to be better when she is either slouched with her head supported and worse when she has to sit upright and hold her posture.
Taft, C. T., Street, A. E., Marshall, A. D., Dowdall, D. J., & Riggs, D. S. (2007). Posttraumatic
Neck pain is categorised clinically as either non-specific or pathologic. Non-specific neck pain is pain in the cervical spine without any identifiable evidence of disease or trauma that could be attributed to it and typically presents with local tenderness or axial tenderness dorsally that may refer into the head, upper thoracic spine, chest or upper extremities (Tsakitzidis and Remmen, 2003; Nordin et al., 2008; Borghouts et al., 1998; Ferrari and Russell, 2003). Non-specific neck pain of mechanical origin may be associated with physiological and emotional stress, prolonged postures, trauma, referred pain or nerve root entrapment in the cervical spine (Barnard and Karnath, 2012). It can also be a component of disk herniation’s, headaches, temporomandibular syndromes, and fibromyalgia may also be associated with neck pain (Nordin et al., 2008).
Mulligan, R.P. and R.C. Mahabir, The prevalence of cervical spine injury, head injury, or both with isolated and multiple craniomaxillofacial fractures. Plast Reconstr Surg, 2010. 126(5): p. 1647-51.