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Orthopedic Case Studies

571 Words3 Pages

The claimant has a past medical history significant for obesity, diabetes mellitus, and hypertensive disorder.

A visit note from Robert Dean, MD (Internal Medicine), dated 05/11/2017, indicated that the claimant was recently in a motor vehicle accident and since then, she had persistent neck, left shoulder, and lower back pain. A review of the systems was positive for musculoskeletal pain, headache, and insomnia. She was diagnosed with cervicalgia, low thoracic rib head displacement, sacroiliitis, and sciatica. Continued therapy and a cervical spine epidural steroid injection were recommended.

An orthopedic evaluation report from Anthony Esposito, DO (Physical Medicine & Rehabilitation), dated 06/08/2017, indicated that the claimant reported neck and low back pain rated as 8/10. He stated that pain was aggravated by bending, climbing stairs, reaching, lying down, coughing, and looking up. Continued chiropractic therapy and MRIs of the …show more content…

Dean, dated 06/14/2017, indicated that the claimant presented with neck pain, left shoulder pain, thoracic pain, lumbar pain, and headaches. She was restricted from prolonged sitting, standing, stooping, pushing, pulling, and lifting more than 10 pounds. She was relieved of work duties from 05/11/2017 - 07/06/2017.

A visit note from Dr. Esposito, dated 07/06/2017, indicated that the claimant presented with persistent neck and lower back pain that radiated to her left upper and left lower extremities. A short-term disability and a 30-day work release were recommended.

An attending physician statement completed by Ali Saifi, MD (Internal Medicine), dated 07/09/2017, indicated that the claimant was unable to perform any work due to constant pain and fatigue. She had complaints of numbness and sharp, burning pain. She was diagnosed with cervical, thoracic, and lumbar degenerative disc disease. She was relieved of work duties from 05/05/2017 - 08/03/2017 and 08/03/2017 -

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934 Words | 4 Pages

2. EMG/NCV studies consistent with peripheral motor and sensory neuropathies, from October 2008 12/15/15 Progress Report described that the patient has ongoing low back pain. He was last seen on 10/28/15. The patient stated that his current medication regimen has been helpful. He rated the pain 9/10-scale level, which is brought down to 6/10-scale level with the medications.

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1383 Words | 6 Pages

He is also receiving chiropractic care and medication which he claims is beneficial. The applicant did have an x-ray of his back. He claimed that the doctor told him his back was not aligned properly. He has not told his treating doctors that he helps his father on a daily

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302 Words | 2 Pages

Although, there was some straightening of the curvature suggesting a muscle spasm. In September of 1985, the plaintiff was rear ended. She suffered a sore neck and soreness in the right shoulder. In April of 1992, the plaintiff was in a motor vehicle accident suffering right leg and groin pain.

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608 Words | 3 Pages

I wanted to give you the respect of a face to face explanation of the issues I found in your medical records, which I believe will make it impossible to recover substantial compensation in this matter. Since we have not been able to meet in person, I will briefly explain why I do not want to pursue this case. The UMDNJ hosptial record for your ER visit on April 7, 2015 indicates “patient states he is using crutches at home secondary to a previous left hip replacement that is recalled and he is waiting for surgery, he missed his step on a loose floor board in the house tonight and fell onto his left side.” You “complained of pain in the left shoulder and unable to fully abduct his arm and also has pain in the left hip area and left

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647 Words | 3 Pages

Pain radiates from the lower back and aggravated by bending, getting in and out of the car, lifting, reciprocating stairs, sitting, standing, turning, twisting and walking which is mildly alleviated by over-the-counter drugs and

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859 Words | 4 Pages

QEP Scripts for Two Recordings – Audio for Musculoskeletal System; “OK, Team! We have a new patient in Room 3B who is being admitted with a progressive (gradual, advancing) decrease in mobility (movement) of his back and legs, and increase in pain located in the lumbosacral (lower back above the tailbone of the spine) area. The patient’s Primary Care Provider has sent along Computed Tomography scans (CT, a rotating x-ray emitter, detailed internal scanner) showing spinal stenosis (narrowing of the spine causing pressure on the nerves and spinal cord causing lower back pain.) and decrease of the normal lordosis (abnormal curvature lower spine, excessive inward curvature of the spine) in the thoracic vertebrae (upper and middle back). Lumbosacral

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685 Words | 3 Pages

This also could have included shooting pain in both the arms and legs. I had the doctor confirm that he never received a history from the claimant of the discrete incident on 12/15/16. I tried to push the doctor off of his opinion on causal relationship, pointing out that there were two different histories of work related injuries but the doctor was insistent that it really did not matter because he felt this was really due to the claimant’s job. He said there might have been an incident that aggravated symptoms but he felt it was part of the heavy duty work the claimant was doing. The doctor did confirm that the claimant was released to return to work without any restrictions on 06/05/17 as he had an excellent result from his surgery.

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691 Words | 3 Pages

All C-8.1s were held in abeyance. Please immediately schedule an IME with an orthopedist on the issue of the neck and the shoulder as we only have forty-five (45) days. My office will schedule the depositions of Dr. Shah and Dr. Guchinskiy. Dr. Guchinskiy is with Crystal Run in Newburgh and Middletown and he examined the claimant on 07/07/17. If you have any questions regarding this hearing, please do not hesitate to contact me.

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1126 Words | 5 Pages

Jean Russell of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with Flavia Tocco and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. INTERVIEW SETTING I met Ms. Tocco at the St. John’s physical therapy department. Ms. Tocco was open to providing me information on her current and prior medical history.

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536 Words | 3 Pages

Requested for a complete copy of the office visit report dated 03/09/16 as the 6th page is missing; however, no medical records received at the time of submission of the review to PA. Current request is for 6 Acupuncture Therapy Sessions for the Right Shoulder and Jaw between 3/25/2016 and 5/24/2016. ort dated 03/09/16 as the 6th page is missing; however, no medical records received at the time of submission of the review to PA. Current request is for 6 Acupuncture Therapy Sessions for the Right Shoulder and Jaw between 3/25/2016 and

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187 Words | 1 Pages

Mary L Walsh is a 84 y.o. female who presented on 5/6/2017 with chief complaint of back pain and leg pain after a fall. Mary was tearful and reported feeling sad. Mary reported she was in significant pain and requested I asked her nurse for more pain medication. Mary reported she fell at home on Saturday but did not tell anyone until her son David came to the home later that day. Mary reported "I am just getting old and having lots of problems".

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830 Words | 4 Pages

This is a 42-year-old female with a 2/7/2015 date of injury. A specific mechanism of injury has not been described. DIAGNOSIS: low back pain; Lumbago with sciatica right side; Myalgia 12/01/15 follow-up visit identified lower back pain. Patient rates the pain as 7/10. The pain is characterized as burning.

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378 Words | 2 Pages

DOI: 1/24/2008. Patient is a 57-year old male medical assistant who sustained injury to her neck and right shoulder due to performing normal work duties. Per OMNI, he was initially diagnosed with cervical radiculopathy and stenosis. He was declared P & S by primary treating physician Dr. Chan on 07/23/09 with 9 % permanent disability (PD). Future medical care includes MD visits, ESIs, acupuncture and medications.

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1382 Words | 6 Pages

The case is about Dr. Hendry, a neurosurgeon, who has been in his first year of practice. Dr. Hendry met his patient, Ms. Davis, who has been experiencing back pain in her right leg for more than a month that started when she bent down to pick up her grandson. Dr. Hendry examined Ms. Davis and noticed that her right leg is slightly weaker than her left with right foot drop. On Ms. Davis’ MRI, it showed that she had ruptured L5-S1 disk and mild degenerative changes (Brody & Zientek, 2007). Dr. Hendry explained the MRI results to Ms. Davis and gave her options to either have the surgery now or wait longer to see if her symptoms will resolve on their own.

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1001 Words | 5 Pages

Chiou et al. (1994) found that the most common diagnosis given to nurses was ‘‘muscular strain’’. Lumbar herniation and mechanical back pain develop as a result of poor body mechanics and damage to the body structures. A. Karahan (2004) found that nurses did not use body mechanics correctly while making some movements. In particular, sitting, lifting, extending, and moving the patient to the side of the bed were not done correctlyby the nurses.

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