Medical Case Study: Work Related Injury

Based on the progress report dated 03/02/16 by Dr. Ozaeta, the patient has had a right knee corticosteroid injection one week ago. She had to take a Norco yesterday for right knee pain. She saw Dr. Cantrell, who requested 8 additional physical therapy sessions. She has low back discomfort, notable when sitting. She takes nortriptyline and an antihypertensive.

Health History: A 25-year-old male injured his left knee in a recent skiing accident. The patient stated that he lost his balance because the inner edge of his right ski got caught while skiing. This resulted in the right leg being externally rotated followed by and audible “pop” as he lost footing. By evening, the right knee joint had become swollen, causing intense pain. The primary care physician referred the case to an orthopedist.

Ingrid is a social worker, wife, and a mother who lives in a two story colonial home with her husband and two daughters, aged 8 and 15 years old. She was active in the school of her children, serving on committees and volunteering to read in the classroom. She attended to church habitually, though her husband did not accompany her. Her interests included swimming, snorkeling, and hiking. Not only was she close to her immediate family, but also maintained frequent contact with her college friends living throughout the country. As well, Ingrid requires moderate assistance with most of her basic activities of daily living (BADL).

DOI: 7/2/2010. The patient is a 57-year old female claims examiner who sustained a work-related cumulative trauma injury to multiple body parts that include head/cervical spine, shoulders, arms knees, and left hip. As per progress report dated 7/11/16, the patient reports neck and low back pain. IT was noted that the pain is associated with left lower extremity numbness, tingling, and weakness. The patient has tried and failed multiple anti-inflammatories, which causes gastrointestinal upset, except for Celebrex. Her psychiatrist, Dr. Nehoryan has recommended her current regimen including Cymbalta and Restoril intermittently for sleep. It was mentioned that the patient had a fall in early 2/2016 due to left lower extremity numbness and is continuing

Based on the progress report dated 02/02/16, the patient presents for evaluation of his bilateral knee pain. He was last seen on 01/05/2016.

Based on the latest medical report dated 03/24/16, the patient presents for follow-up of his right knee pain. He ambulates with a cane. He has completed a series of Hyalgan injections in 09/2015 in the right knee which lasted for 1 month. He would like to begin a new series of Hyalgan injections.

The patient has attended 3 PT sessions for the ankle per daily note dated 04/05/13.

Per the medical report dated 07/06/15, the patient was prescribed with ibuprofen. IW wishes to continue trying to work without restrictions.

DOI: 6/16/2015. Patient is a 61-year-old female quality control who sustained a work-related injury to her lower back while lifting a box. MRI of the lumbar spine dated 8/13/15 revealed mild levoscoliosis; multilevel degenerative disc disease with the most significant disease at the levels of L4-5 and L5-S1. Per orthopedic report dated 05/12/16, the patient has recurrent left L5 radiculopathy and left L4-5 posterolateral disc herniation. She reports proceeding with a course of acupuncture therapy. She said that in doing so, she began to have increased left lower extremity symptoms in the lateral thigh and lateral calf associated with numbness and weakness. She reports pain and discomfort with walking, lumbar leg extension and numbness even at night time with lying

Patient has been previously denied with 1 Right Knee Diagnostic Arthroscopy on 08/04/16 (Review 270777).

Requested for recent progress report, however, no medical records received at the time of submission of the review to PA.

Based on the progress report date03/16/16, the patient has been managed conservatively with PT and has continued to experience discomfort. His pain has migrated from primarily thoracic to more localized lumbar pain.

DOI: 2/10/2016. Patient is a 51-year-old female housekeeper who sustained left knee injury when another employee from the hotel accidentally hit her knee with the housekeeping cart. As per OMNI, she was initially diagnosed with tear in left knee. He is status post left knee arthroscopy on 6/23/2016.

During clinical this week, my eyes were opened to the reality of looking at the patient from a holistic perspective. It all started with the concept of my patient having a work-related injury. I often hear about these unfortunate events, however I have never actually cared for an individual who has gone through this, until this week. J.K arrived to the Emergency Department the evening of September 29th. His diagnosis was a bilateral hand crush injury from a mechanical machinery safety fail. My patient suffered various fractures in multiple metacarpal bones of the finger, as well as hand. As a result, they lost function in both hands for a hopefully temporary period of time. He later mentioned the soonest he will be able to return to work would be 3 months at the

DOI: 02/11/2016. Patient is a 50-year-old male carpenter who sustained a work-related injury while at work. The patient was subsequently diagnosed with contusion of scalp, initial encounter; and Sprain of other ligament of right ankle, initial encounter. Per medical report dated 4/21/2016, the patient complained of frequent severe pain in the head and lumbar spine that was described as sharp. The headache is associated with dizziness. The patient has completed 12 physical medicine sessions to date and showed significant functional improvement as manifested by increased activities of daily living. The patient was then declared temporarily totally disabled until 6/21/2016. As per progress report dated 6/2/16, the patient complains of frequent