DOI: 4/30/2013. The patient is a 41-year old male maintenance technician who sustained a work-related injury to his right shoulder/arm from lifting ladders all day. As per OMNI, the patient is permanent and Stationary as of 8/23/2013 with future medical care to include medications, creams, and possible need for injections. As per office notes dated 7/13/16, the patient co complained of bilateral leg and feet pain, back pain, neck pain and low back pain. The patient’s pain is rated as 7 to 10; average of 8. Medications improves his condition. The pain is characterized as sharp, throbbing, bruning, aching, electricity, and pins and needles. The pain is constant and radiating. It is increased by sitting, standing, lying down, bending, and lifting. Previous treatments include …show more content…
It was also noted that the office will give a new lap slip. It was also noted that the patient is scheduled for a repeat caudal epidural steroid injection. Physical examination revealed that the cervical spine has decreased range of motion; tenderness to palpation at the paraspinal muscle; spasm at the bilateral cervical trigger point, bilateral trapezius rigger point, and bilateral rhomboid trigger point. There is also bilateral tenderness to palpation of facet joints C5-C7, positive Spurling’s test, foraminal compression test. Physical examination of the lumbar spine revealed decreased range of motion on all planes; tenderness to palpation at the lumbar paraspinous area; tenderness to palpation over the lumbar spine; bilateral straight leg raise; bilateral knee extension weakness, bilateral lumbar radicular sign, and spasm noted. Assessment includes spondylosis without myelopathy or radiculopathy, lumbosacral region; radiculopathy, lumbar region; cervical disc disorder, unspecified, cervicothoracic region; radiculopathy, cervical region; other cervical disc displacement, unspecified cervical region; other cervical disc displacement, lumbar region; testicular