This is a 60-year-old male with a 10/01/2015 date of injury. A specific mechanism of injury has not been described.
DIAGNOSES:
1. Cervical discogenic pain/bilateral cervical facet pain C2-# and C5-C6/ cervical sprain/strain.
2. Bilateral cervical radicular pain C5-C6 L>R
3. Cervicogenic neck pain with cervicogenic headaches/bilateral occipital neuralgia.
4. Bilateral shoulder sprain/strain.
5. Bilateral wrist sprain/strain/bilateral carpal tunnel syndrome.
6. Bilateral hand/ first metacarpal joint pain.
7. Lumbar discogenic pain/ bilateral lumbar facet pain L4-L5 and L5-S1/ lumbar sprain/strain.
8. Bilateral lumbosacral radicular pain L5.
12/02/15 Progress Report indicated that the patient is complaining of constant bilateral shoulder pain. …show more content…
Activity aggravates the pain and medications improve it. The patient also has constant neck pain radiating into both upper extremities, both thumbs ad all fingers associated with tingling, numbness, weakness and cramps. The patient rated neck pain as 3-7/10-scale level. The pain aggravates with neck rotation and neck movements. Medications relieve it. There is also 3-7/10-sclae level pain in bilateral wrists, hands and thumbs L>R. The pain is aggravated by the use of both hands and relieved by medications and rest. The patient has constant lower back pain radiating into both lower extremities and big toe associated with weakness. The back pain is rated as 3-6/10-scale level. Prolonged sitting and standing aggravate the pain. Medications and rest relieve it. The pain is described as sharp, shooting and aching pain. The patient has tingling, numbness involving both hands and muscle spasms in both shoulders. Coughing, sneezing, prolonged sitting and standing aggravate the neck and …show more content…
The patient is stiff in the morning. The patient has headaches, which start from the neck localized to occipital area. The headaches are bilateral. The patient cannot sit, stand, or drive in one position. The patient frequently changes position to get comfortable. The pain affects his sleep. The patient has a history of NSAID induced gastritis, dyspepsia and is placed on Prilosec. The patient is recommended to take Tramadol. He is allowed Naprosyn, Prilosec and Ultram. The exam of the neck revealed midline tenderness extending from C2 to C6. Bilateral facet tenderness is noted at C2-C3 and C5-C6. Bilateral occipital tenderness is noted. Pressure causes occipital type of headaches. Bilateral trapezius muscle tenderness is noted. Cervical spine movements still remain painful. The exam of the lower back showed midline tenderness extending form L3 to S1. There was bilateral lumbar facet tenderness at L4-L5 and L5-S1. There is also mild bilateral sacroiliac and sciatic notch tenderness. Thoracic and lumbar spine movements still remain painful. The exam of the right and left shoulder showed tenderness over anterior, posterior and superior aspect of both shoulders. ROM of shoulder joint is restricted in all planes. Exam of the
DIAGNOSES:
1. Cervical discogenic pain/bilateral cervical facet pain C2-# and C5-C6/ cervical sprain/strain.
2. Bilateral cervical radicular pain C5-C6 L>R
3. Cervicogenic neck pain with cervicogenic headaches/bilateral occipital neuralgia.
4. Bilateral shoulder sprain/strain.
5. Bilateral wrist sprain/strain/bilateral carpal tunnel syndrome.
6. Bilateral hand/ first metacarpal joint pain.
7. Lumbar discogenic pain/ bilateral lumbar facet pain L4-L5 and L5-S1/ lumbar sprain/strain.
8. Bilateral lumbosacral radicular pain L5.
12/02/15 Progress Report indicated that the patient is complaining of constant bilateral shoulder pain. …show more content…
Activity aggravates the pain and medications improve it. The patient also has constant neck pain radiating into both upper extremities, both thumbs ad all fingers associated with tingling, numbness, weakness and cramps. The patient rated neck pain as 3-7/10-scale level. The pain aggravates with neck rotation and neck movements. Medications relieve it. There is also 3-7/10-sclae level pain in bilateral wrists, hands and thumbs L>R. The pain is aggravated by the use of both hands and relieved by medications and rest. The patient has constant lower back pain radiating into both lower extremities and big toe associated with weakness. The back pain is rated as 3-6/10-scale level. Prolonged sitting and standing aggravate the pain. Medications and rest relieve it. The pain is described as sharp, shooting and aching pain. The patient has tingling, numbness involving both hands and muscle spasms in both shoulders. Coughing, sneezing, prolonged sitting and standing aggravate the neck and …show more content…
The patient is stiff in the morning. The patient has headaches, which start from the neck localized to occipital area. The headaches are bilateral. The patient cannot sit, stand, or drive in one position. The patient frequently changes position to get comfortable. The pain affects his sleep. The patient has a history of NSAID induced gastritis, dyspepsia and is placed on Prilosec. The patient is recommended to take Tramadol. He is allowed Naprosyn, Prilosec and Ultram. The exam of the neck revealed midline tenderness extending from C2 to C6. Bilateral facet tenderness is noted at C2-C3 and C5-C6. Bilateral occipital tenderness is noted. Pressure causes occipital type of headaches. Bilateral trapezius muscle tenderness is noted. Cervical spine movements still remain painful. The exam of the lower back showed midline tenderness extending form L3 to S1. There was bilateral lumbar facet tenderness at L4-L5 and L5-S1. There is also mild bilateral sacroiliac and sciatic notch tenderness. Thoracic and lumbar spine movements still remain painful. The exam of the right and left shoulder showed tenderness over anterior, posterior and superior aspect of both shoulders. ROM of shoulder joint is restricted in all planes. Exam of the