Case Study Summary: An Explanation Of Injury

813 Words 4 Pages
This is a 60-year-old male with a 10/01/2015 date of injury. A specific mechanism of injury has not been described.

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.
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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 back pain. The patient is stiff in the morning. …show more content…
11/04/15 DWC Form RFA for flexion/extension X-Ray of lumbar spine; X-Ray bilateral shoulders; X-rays bilateral wrists and thumbs; MRI of Cervical spine; MRI of Lumbar spine; EMG/NCS UPPER Extremities; EMG/NCS - Lower extremities; Naprosyn 500 mg b.i.d #60; Prilosec 20mg #30 one a day; Ultram 50mg #30 b.i.d. p.r.n. pain; Compounded medication:
A) Flurlido-A (Flurbiprofen 20%, Lidocaine 5%/Amitriptyline 5%) #1tube and B) Ultraflex G (gabapentin 10%, Cyclobenzaprine 6%, Tramadol 10%) #1 tube; and Re-evaluation in 4 weeks.

11/04/15 Progress Report indicated that the patient has neck pain, shoulder pain, back pain and bilateral wrist, hand and thumb pain. Exam revealed tenderness to palpation in the cervical spine, lumbar spine and shoulders. ROM was restricted in shoulders and bilateral wrists. Tinel’s sign, Phalen’s sign and carpal tunnel compression test were positive. Treatment plan was X-rays, MRI, EMG/NCS and medications. The patient prefers less oral medications and that is why compounded oral medication had been recommended. The patient is TTD till 12/15/15. Follow up in 4 weeks.

Treatment to date includes

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