Injury Case Studies
DOI: 11/24/2014. The patient is a 59-year-old male carpenter who sustained injury to his right arm/shoulder and right leg when he fell while from a ladder, amended to include the right wrist. Per OMNI, he had a complete tear of the supraspinatus tendon with retraction per MRI and underwent a rotator cuff tear surgery on 2/5/15.
Based on the medical report dated 12/14/15, the patient is still having similar problems. He is having significant neck pain going down to the right arm with tingling sensation as well as in the right hand. In addition, he has right lower leg pain and tingling.
On examination, the right “APB” is 4/5 and the right hand grip is 4/5. Sensation is decreased to pinprick in the right peroneal distribution and right median …show more content…
Impression includes right foot numbness, rule out peroneal neuropathy given previous right ankle and foot injury, also to rule out underlying lumbar radiculopathy, right carpal tunnel and possible cervical radiculopathy.
Treatment plan includes EMG of the upper and lower extremities, MRI of the lumbar spine, continuation with Neurontin and Naprosyn for pain control, shoulder arthropathy and physical therapy.
Per the PT note dated 12/16/15, the patient continues to report numbness in midline of forearm extending from elbow to all fingers. Pain is rated 8/10 on the right. He also reports numbness extending from elbow to all fingers in midline of forearm. Phalen sign is positive.
Active range of motion shows wrist flexion is 70 degrees, extension is 50 degrees, ulnar deviation is 25 degrees and radial deviation is 10 degrees.
Motor power is graded 4+/5 in wrist motions. He is able to make a full fist. Grip strength is 20 kgw to the right and 42 kgw to the left, at # 6 setting on hand dynamometer. Objects no longer fall from hand. IW has difficulty manipulating small objects (keys, coins, and button, etc.). Goals are to alleviate pain to 0/10 and to improve motor power and function in the right upper extremity. Patient will be treated three times per week for four
Based on the medical report dated 12/14/15, the patient is still having similar problems. He is having significant neck pain going down to the right arm with tingling sensation as well as in the right hand. In addition, he has right lower leg pain and tingling.
On examination, the right “APB” is 4/5 and the right hand grip is 4/5. Sensation is decreased to pinprick in the right peroneal distribution and right median …show more content…
Impression includes right foot numbness, rule out peroneal neuropathy given previous right ankle and foot injury, also to rule out underlying lumbar radiculopathy, right carpal tunnel and possible cervical radiculopathy.
Treatment plan includes EMG of the upper and lower extremities, MRI of the lumbar spine, continuation with Neurontin and Naprosyn for pain control, shoulder arthropathy and physical therapy.
Per the PT note dated 12/16/15, the patient continues to report numbness in midline of forearm extending from elbow to all fingers. Pain is rated 8/10 on the right. He also reports numbness extending from elbow to all fingers in midline of forearm. Phalen sign is positive.
Active range of motion shows wrist flexion is 70 degrees, extension is 50 degrees, ulnar deviation is 25 degrees and radial deviation is 10 degrees.
Motor power is graded 4+/5 in wrist motions. He is able to make a full fist. Grip strength is 20 kgw to the right and 42 kgw to the left, at # 6 setting on hand dynamometer. Objects no longer fall from hand. IW has difficulty manipulating small objects (keys, coins, and button, etc.). Goals are to alleviate pain to 0/10 and to improve motor power and function in the right upper extremity. Patient will be treated three times per week for four