DOI: 6/27/2015. Patient is a 55-year-old male route sales representative who sustained injury when he was involved in a motor vehicle accident (head-on collision) while he was seated on the passenger side. Per OMNI, he was initially diagnosed with contusion of the chest wall, cervical and lumbar strain and contusion and abrasion to the right elbow, right knee, shoulders and right groin.
Per the medical report by Dr. Tabibian dated 09/10/15, the patient complained of pain to his neck, bilateral shoulders, right elbow, chest, low back, right knee and bilateral ankles. He also reported weakness, bruises and purplish discoloration in his both wrists with difficulty lifting and holding objects. He also has a “purplish discoloration” in his right groin and right testicles, with difficulty urinating. He also reported difficulty sleeping, stress, anxiety and depression. He is currently taking Tylenol 500 mg twice daily. Diagnoses are shoulder impingement, wrist sprain/strain, carpal tunnel syndrome, lumbar sprain/strain and inguinal hernia. He was given prescription for Ketoprofen, omeprazole and orphenadrine. …show more content…
There is no rotator cuff tear. Mild acromioclavicular joint arthrosis is seen.
Based on the progress report by Dr. Rashti dated 12/18/15, the patient reports that he is feeling the same. Pain is rated as 10/10. Physical functioning, family/social relationships, mood and overall functioning are the same with current pain relievers. Sleep patterns have worsened. No side effects from medications are
Per the medical report by Dr. Tabibian dated 09/10/15, the patient complained of pain to his neck, bilateral shoulders, right elbow, chest, low back, right knee and bilateral ankles. He also reported weakness, bruises and purplish discoloration in his both wrists with difficulty lifting and holding objects. He also has a “purplish discoloration” in his right groin and right testicles, with difficulty urinating. He also reported difficulty sleeping, stress, anxiety and depression. He is currently taking Tylenol 500 mg twice daily. Diagnoses are shoulder impingement, wrist sprain/strain, carpal tunnel syndrome, lumbar sprain/strain and inguinal hernia. He was given prescription for Ketoprofen, omeprazole and orphenadrine. …show more content…
There is no rotator cuff tear. Mild acromioclavicular joint arthrosis is seen.
Based on the progress report by Dr. Rashti dated 12/18/15, the patient reports that he is feeling the same. Pain is rated as 10/10. Physical functioning, family/social relationships, mood and overall functioning are the same with current pain relievers. Sleep patterns have worsened. No side effects from medications are