DOI: 2/19/2011. Patient is a 59-year-old female licensed vocational nurse who sustained a work-related injury to her right ankle, head, left hand, arm, right foot, toe and left knee when she tripped over a stone and fell. As per OMNI, she was diagnosed with head contusion, lumbar strain, left elbow contusion/tibial plateau fracture, and fracture of the right fifth metatarsal.
MRI of the left knee obtained on 09/24/11 showed chronic depressed lateral tibial plateau fracture with depression of approximately 6 mm peripherally, lateral meniscus tear, chondral flap lesion medial femoral condyle anteriorly, condyle flap lesion of the lateral patellar facet, synovitis and joint effusion.
Per the Ortho AME report dated 01/13/15 by Dr. Wood, patient …show more content…
Treatment plan includes a left knee CL-hinged knee brace with suspension sleeve to prevent further instability and valgus malalignment, and to provide stability and facilitate maintenance of Activities of Daily Living. There is concern in regard to instability, near falls, and actual falls due to instability of the left knee. There is also a concern in regard to development of derivative injury if falls occur thereby, complicate the case and add to costs.
An updated MRI scan of her left knee is also requested to determine whether additional surgery is indicated, as her symptoms are progressively getting worse.
A prescription for the following was provided: naproxen 500 mg #60 1 tablet twice daily; Norflex ER 100 mg #30 1 tablet daily; omeprazole 20 mg #60 1 tablet twice daily; and Xanax 0.5 mg #60 1 tablet twice
MRI of the left knee obtained on 09/24/11 showed chronic depressed lateral tibial plateau fracture with depression of approximately 6 mm peripherally, lateral meniscus tear, chondral flap lesion medial femoral condyle anteriorly, condyle flap lesion of the lateral patellar facet, synovitis and joint effusion.
Per the Ortho AME report dated 01/13/15 by Dr. Wood, patient …show more content…
Treatment plan includes a left knee CL-hinged knee brace with suspension sleeve to prevent further instability and valgus malalignment, and to provide stability and facilitate maintenance of Activities of Daily Living. There is concern in regard to instability, near falls, and actual falls due to instability of the left knee. There is also a concern in regard to development of derivative injury if falls occur thereby, complicate the case and add to costs.
An updated MRI scan of her left knee is also requested to determine whether additional surgery is indicated, as her symptoms are progressively getting worse.
A prescription for the following was provided: naproxen 500 mg #60 1 tablet twice daily; Norflex ER 100 mg #30 1 tablet daily; omeprazole 20 mg #60 1 tablet twice daily; and Xanax 0.5 mg #60 1 tablet twice