Tenderness Case Studies

DOI: 8/11/2015. Patient is a 40-year-old male foreman who sustained a work-related injury to his mid and low back when the safety rope jerked to stop him from falling while climbing down a tree. Per OMNI, he was initially diagnosed with lumbar strain.
Per medical report dated 10/5/16, patient was prescribed with tramadol for breakthrough pain, Relafen for anti-inflammatory, and Prevacid for gastrointestinal prophylaxis.
Based on the medical report dated 10/26/16, the patient has continued with his self-treatment and remains symptomatic. He has not been seen for pain management evaluation or received additional therapy.
On examination of the cervical spine, there is tenderness to palpation over the upper, mid, and lower paravertebral and trapezius muscles. Range of motion shows flexion and extension of 40 degrees, lateral bending to 35 degrees on the right and 40 degrees on the left, and lateral rotation to 45 degrees and 50 degrees on the left. There is increased pain with extension.
There is mild limitation of motion.
On examination of the right elbow, there is tenderness to palpation over the lateral epicondyle and the extensor origin. There is pain with resisted/repetitive dorsiflexion of the wrist. Range of motion shows extension of 0 degrees, flexion of 125 degrees, pronation of 80 degrees and supination of 80