This is a 59-year-old female with a 7/29/2009 date of injury, due to a slip and fall.
DIAGNOSIS:
Cervicalgia; C4-7 anterior cervical decompression and fusion 2014; Lumbar/cervical disc degeneration.
12/15/15 Progress Report described that the patient has significant neck pain radiating to he right upper extremity with weakness and increased elbow pain. She still continues to have severe back pain. She still has lower back pain and occasional lower extremity pain. She gets some pain relief with the use of her medication. The patient rates the pain as 7/10-scale level with medications. Movement aggravates the pain and medications make it better. The patient complains of abdominal pain, indigestion, heartburn, frequent constipation, frequent …show more content…
She complained of significant back pain. The patient rates the pain as 7/10-scale leve; currently. The pain is 7/10-scale level with the medications and 10/10-scale level without medications. Looking up and bending over aggravate the pain. Cold, heat, lying down and medications relieve the pain. The patient claimed abdominal pain, indigestion, heartburn, frequent constipation, frequent diarrhea, painful bowel movements and chronic bloating. The patient also complains of difficulty urinating and inability to control urine. Musculoskeletal system review revealed muscle pain, shoulder pain, back pain, and morning stiffness. Psychiatry assessment revealed anxiety, depressed mood, mood swings, nervousness and difficulty sleeping. Examination of the neck revealed muscle spasms, tenderness to palpation at C3 to C7. Tender facet joints at C3 to C7 bilaterally with positive provocation test. There was decreased ROM at the cervical spine. Muscle strength was 4/5 and sensations to touch over the left medial and lateral aspect of the forearm were diminished. The exam of the back showed tenderness to palpation at L1 to S1. Tender facet joints at L1 to S1 bilaterally with positive provocation test. There were decreased ROM and positive spasms. SLR was positive. The sensation to touch was decreased at the right L4, L5 and S1 nerve root distributions. Treatment plan included continuation of Carisoprodol, Cymbalta, Omeprazole, Docusate sodium and Oxycodone. The follow-up was in 1
DIAGNOSIS:
Cervicalgia; C4-7 anterior cervical decompression and fusion 2014; Lumbar/cervical disc degeneration.
12/15/15 Progress Report described that the patient has significant neck pain radiating to he right upper extremity with weakness and increased elbow pain. She still continues to have severe back pain. She still has lower back pain and occasional lower extremity pain. She gets some pain relief with the use of her medication. The patient rates the pain as 7/10-scale level with medications. Movement aggravates the pain and medications make it better. The patient complains of abdominal pain, indigestion, heartburn, frequent constipation, frequent …show more content…
She complained of significant back pain. The patient rates the pain as 7/10-scale leve; currently. The pain is 7/10-scale level with the medications and 10/10-scale level without medications. Looking up and bending over aggravate the pain. Cold, heat, lying down and medications relieve the pain. The patient claimed abdominal pain, indigestion, heartburn, frequent constipation, frequent diarrhea, painful bowel movements and chronic bloating. The patient also complains of difficulty urinating and inability to control urine. Musculoskeletal system review revealed muscle pain, shoulder pain, back pain, and morning stiffness. Psychiatry assessment revealed anxiety, depressed mood, mood swings, nervousness and difficulty sleeping. Examination of the neck revealed muscle spasms, tenderness to palpation at C3 to C7. Tender facet joints at C3 to C7 bilaterally with positive provocation test. There was decreased ROM at the cervical spine. Muscle strength was 4/5 and sensations to touch over the left medial and lateral aspect of the forearm were diminished. The exam of the back showed tenderness to palpation at L1 to S1. Tender facet joints at L1 to S1 bilaterally with positive provocation test. There were decreased ROM and positive spasms. SLR was positive. The sensation to touch was decreased at the right L4, L5 and S1 nerve root distributions. Treatment plan included continuation of Carisoprodol, Cymbalta, Omeprazole, Docusate sodium and Oxycodone. The follow-up was in 1