DOI: 4/8/2011. Patient is a 63-year-old male route sales representative who sustained injury when he was taking bread rack off the left gate and he ended up falling off the truck and the rack fell on him. Per OMNI entry, IW is status post left knee surgery on 09/20/11 and right knee surgery on 02/26/16.
Based on the progress report dated 09/21/16 by Dr. Pelton, the patient complains of persistent pain in neck which he rates at 6/10, it is constant and radiates to the shoulders and pain in the lower back at 7/10, it is constant and radiates down to both legs. He also complains of pain in the right shoulder at 6/10 and pain in the right hand at 6/10 with stiffness. He also has pain in the bilateral knees at 8/10, the right one is worse this …show more content…
There was tenderness diffusely to palpation.
Examination of the knees revealed decreased range of motion. Palpation of the medial joint line and lateral joint line revealed tenderness on the right. Valgu and Varus stress tests were positive on the right. Patellofemoral Grind test was positive bilaterally.
Patient was diagnosed with bilateral knee posttraumatic end-stage osteoarthritis, status post left total knee arthroplasty, status post right knee arthroscopy, cognitive disorder with vertigo, depression, lumbar strain and cervical strain.
Treatment plan includes physical therapy to the right hand, Nabumetone, psychiatrist consultation for possible antidepressant as he is complaining of depression, stress and anxiety due to chronic pain and his situation, and neurology consultation for persistent headaches and due to the closed head trauma with loss of consciousness and complaints of vertigo.
MD feels that he should be assessed by a neurologist at this time, as he has persistent symptoms status post head trauma.
He will continue his medications.
Current request is for 1 Consultation with a Neurologist between 10/11/2016 and
Based on the progress report dated 09/21/16 by Dr. Pelton, the patient complains of persistent pain in neck which he rates at 6/10, it is constant and radiates to the shoulders and pain in the lower back at 7/10, it is constant and radiates down to both legs. He also complains of pain in the right shoulder at 6/10 and pain in the right hand at 6/10 with stiffness. He also has pain in the bilateral knees at 8/10, the right one is worse this …show more content…
There was tenderness diffusely to palpation.
Examination of the knees revealed decreased range of motion. Palpation of the medial joint line and lateral joint line revealed tenderness on the right. Valgu and Varus stress tests were positive on the right. Patellofemoral Grind test was positive bilaterally.
Patient was diagnosed with bilateral knee posttraumatic end-stage osteoarthritis, status post left total knee arthroplasty, status post right knee arthroscopy, cognitive disorder with vertigo, depression, lumbar strain and cervical strain.
Treatment plan includes physical therapy to the right hand, Nabumetone, psychiatrist consultation for possible antidepressant as he is complaining of depression, stress and anxiety due to chronic pain and his situation, and neurology consultation for persistent headaches and due to the closed head trauma with loss of consciousness and complaints of vertigo.
MD feels that he should be assessed by a neurologist at this time, as he has persistent symptoms status post head trauma.
He will continue his medications.
Current request is for 1 Consultation with a Neurologist between 10/11/2016 and