DOI: 2/10/2015. Patient is a 48-year-old female transaction processor who sustained injuries to her left side and back when she slipped and fell in the lunchroom. Per OMNI, she was diagnosed with low back strain, left sided low back pain with left sided and lower back injury.
Based on the progress report dated 04/15/16 by Dr. Quesada, the patient complains of worsening mid/low back pain, rated as 8-9/10. She states that she has radiation going down her left leg to her knee. She states her symptoms increase with standing, bending, lifting and sitting, and decrease with rest, medications and walking.
She also complains of constant right forearm pain, rated as 8- 9/10. The pain starts in her right wrist and radiates up her forearm to her right elbow. She also has a numbness, tingling, and stiffness sensation. The pain increases when lifting, and decreases with medications.
She also complains of persistent depression and insomnia due to pain, stress, …show more content…
She has limited range of motion secondary to pain.
Sitting root and straight leg raise is positive. Strength is 2+/5.
On examination of the right elbow/forearm, she has tenderness to palpation of the right lateral epicondyle and the extensors. She has limited range of motion secondary to pain. Strength is 3+/5.
On examination of the right wrist/hand, she has tenderness to palpation of the right wrist joint. She has limited range of motion secondary to pain. Strength is 3+/5.
Diagnoses include lumbar sprain/strain with radiculitis, right arm contusion, right elbow/forearm,/wrist sprain/strain and L5-S1 3-mm anterolisthesis, L5-S1 3-mm broad based disc protrusion, right wrist partial tear of the triangular fibrocartilage complex (TFCC) and scapholunate ligament, right wrist carpal tunnel syndrome, chronic pain, depression and
Based on the progress report dated 04/15/16 by Dr. Quesada, the patient complains of worsening mid/low back pain, rated as 8-9/10. She states that she has radiation going down her left leg to her knee. She states her symptoms increase with standing, bending, lifting and sitting, and decrease with rest, medications and walking.
She also complains of constant right forearm pain, rated as 8- 9/10. The pain starts in her right wrist and radiates up her forearm to her right elbow. She also has a numbness, tingling, and stiffness sensation. The pain increases when lifting, and decreases with medications.
She also complains of persistent depression and insomnia due to pain, stress, …show more content…
She has limited range of motion secondary to pain.
Sitting root and straight leg raise is positive. Strength is 2+/5.
On examination of the right elbow/forearm, she has tenderness to palpation of the right lateral epicondyle and the extensors. She has limited range of motion secondary to pain. Strength is 3+/5.
On examination of the right wrist/hand, she has tenderness to palpation of the right wrist joint. She has limited range of motion secondary to pain. Strength is 3+/5.
Diagnoses include lumbar sprain/strain with radiculitis, right arm contusion, right elbow/forearm,/wrist sprain/strain and L5-S1 3-mm anterolisthesis, L5-S1 3-mm broad based disc protrusion, right wrist partial tear of the triangular fibrocartilage complex (TFCC) and scapholunate ligament, right wrist carpal tunnel syndrome, chronic pain, depression and