Skeletal Disorders Case Summary
DOI: 06/05/2010. Patient is a 69-year-old female registered nurse who fractured her right fibula when the bicycle she was riding slid onto gravel throwing her to the ground. Per OMNI, PQME Dr. Litoff indicated on 09/10/12 that the IW has a 16% permanent disability with future medical care of injections and possible surgery for the left shoulder and home exercise for the right wrist and lumbar spine.
Based on the progress report dated 02/02/16, the patient presents for follow up for left shoulder and right wrist pain. She has had constant shoulder pain and wrist pain with exacerbation of symptoms recently with movements. Patient would like to have MRI done to see what is causing pain. She has had one shoulder injection which helped but wants
to see what MRI results show. Over the counter medications do not seem to help.
On examination of the left shoulder, there is tenderness to palpation anteriorly. Impingement sign is positive. The right mid-forearm is tender to palpation.
On examination of the lumbar spine, paravertebral muscles are tender.
Spasm is present. Range of motion is restricted. Sensation is reduced in bilateral S1 dermatomal distribution. Achilles tendon reflexes are absent bilaterally. Patellar reflexes 1+ on the right and absent on the left. Straight leg raising is positive on the left.
Current medications include omeprazole delayed release 20 mg, Medrox pain relief ointment, hydrocodone 5-325 mg, naproxen sodium 550 mg, Ketoprofen extended release 200 mg 1 capsule daily and Tylenol-codeine#3.
Diagnoses include unspecified joint derangement, lumbar region radiculopathy and other fracture of lower end of unspecified tibia, initial encounter for closed fracture.
Treatment plan includes continuation with medications, open MRI of the left shoulder and right wrist due to IW’s weight and right wrist brace. Tylenol was discontinued.
She will follow-up in 4 weeks.
Per verification to the provider’s office, there is no available information on the IW’s weight.
Current request is for 30 Capsules of Ketoprofen Extended-Release 200mg with 2 Refills between 2/9/2016 and 4/9/2016.
This is 2 out of 2 referrals.
Based on the progress report dated 02/02/16, the patient presents for follow up for left shoulder and right wrist pain. She has had constant shoulder pain and wrist pain with exacerbation of symptoms recently with movements. Patient would like to have MRI done to see what is causing pain. She has had one shoulder injection which helped but wants
to see what MRI results show. Over the counter medications do not seem to help.
On examination of the left shoulder, there is tenderness to palpation anteriorly. Impingement sign is positive. The right mid-forearm is tender to palpation.
On examination of the lumbar spine, paravertebral muscles are tender.
Spasm is present. Range of motion is restricted. Sensation is reduced in bilateral S1 dermatomal distribution. Achilles tendon reflexes are absent bilaterally. Patellar reflexes 1+ on the right and absent on the left. Straight leg raising is positive on the left.
Current medications include omeprazole delayed release 20 mg, Medrox pain relief ointment, hydrocodone 5-325 mg, naproxen sodium 550 mg, Ketoprofen extended release 200 mg 1 capsule daily and Tylenol-codeine#3.
Diagnoses include unspecified joint derangement, lumbar region radiculopathy and other fracture of lower end of unspecified tibia, initial encounter for closed fracture.
Treatment plan includes continuation with medications, open MRI of the left shoulder and right wrist due to IW’s weight and right wrist brace. Tylenol was discontinued.
She will follow-up in 4 weeks.
Per verification to the provider’s office, there is no available information on the IW’s weight.
Current request is for 30 Capsules of Ketoprofen Extended-Release 200mg with 2 Refills between 2/9/2016 and 4/9/2016.
This is 2 out of 2 referrals.