Workplace Injury: Impact and Rehabilitation Progress

his is a 36-year-old male with a 7/3/2015 date of injury, when a large pile of boxes containing Octopus weighing around 50 pounds each, fell on the patient.

DIAGNOSIS: Lumbago

Cervicalgia

Left shoulder pain

CTS

12/31/15 Acupuncturist Evaluation Report noted that the patient has attended 3 sessions. He has 5/10-scale level pain in the cervical spine; 6/10-scale level pain in the lumbar spine; 6/10-scale level pain in the left shoulder; and 4/10-scale level pain in the left wrist and left hand. The patient has experienced reduction in pain and weakness. He never had sleep disturbance, headaches or stress. Since the last report, the patient has experienced improved functional capacity, can walk more, can perform more activities of daily living,

Repetitive neck movements or keeping the neck in a fixed position aggravates the pain. The patient also complains of constant 5-6/10-scale level pain in the thoracic spine and lumbar spine. Heavy lifting, repetitive bending, twisting, and stooping aggravate the pain. The pain is improved by shifting positions. There is also frequent 5/10-scale level left shoulder pain. Current medications: Prevacid and Vitamins. The patient reports difficulty with some activities of daily living. There were reported sleep problems and difficulty with sexual function. The exam revealed limited ROM in the lumbar spine. He can extend his knees fully. SLR was positive bilaterally. There is paraspinal spasm and tenderness. There is facet joint tenderness. There was positive Tinel’s, positive Phalen’s and positive Finkelstein’s test on the left. Cervical: The ROM was reduced. There was paraspinal tenderness, tightness, spasm, muscle guarding at trapezius, rhomboid muscle groups at the base of the neck on the left side. Left Shoulder: ROM was reduced. There was positive impingement sign. There was tenderness to rotator cuff and tenderness over bicipital groove, on the left. Treatment plan: X-rays of the cervical spine, lumbar spine and left shoulder; MRI of the cervical spine, lumbar spine, and left shoulder; EMG/NCV of the upper extremities; Fiorcet,

The November progress report documented that the patient has constant 5-6/10-scale level cervical pain, constant 5-6/10-scale level pain in the thoracic spine and lumbar spine pain, and frequent 5/10-scale level left shoulder pain and wrist pain. The physical exam revealed limited ROM and tenderness to palpation over the paining areas. However, the Acupuncture Evaluation Reports do not show any significant improvement in the levels of pain. The level of pain has more or less remained the same. It was noted in the 12/31/15 evaluation report that the activities of daily living have improved and ROM has increased, however, there was no physical exam performed. There was no proper history documented along with the evaluation. There are no latest patient progress reports available for review. The last physical examination was performed in November. It was noted that the patient has attended 3 sessions so far. He is approved for 2 X per week for 4-6 weeks. The therapy is still ongoing, however, only initial 2 reports for 3 sessions have been