Work-Related Injury

DOI: 3/3/2016. Patient is a 59-year-old male senior mechanic who sustained a work-related injury to his left hand/wrist, left shoulder, hip, back, and neck when he lost balance and fell while unloading furniture from truck. Per OMNI entry, he was initially diagnosed with fracture of the left hand and sprain/strain of the left shoulder and back.
Based on the medical report dated 01/10/17, the patient complains of pain in the neck and low back, right leg and left arm. Pain is described as dull/aching, shooting, tightness and tingling. Pain radiates to the right leg/above knee and right leg/below knee. Pain is relieved with rest, medications, ice, heat, massage, PT and injection. Therapy alleviates the pain. Pain is exacerbated by stretching, sitting, standing, twisting, walking, bending forward, exercise and stairs. Patient reports drowsiness and constipation, as related to the side effects of medications.
Cervical range of motion shows lateral rotation is 60 degrees, bilaterally. Strength testing reveals 5-/5 over the right deltoid and left biceps.
On examination of the back, palpation of the thoracic/lumbar spine shows bilateral lumbar paraspinal spasm and tenderness, right sacroiliac joint tenderness, and numbness/tingling of the right leg and foot. Range of motion of the thoracic and lumbar spine reveals pain at extremes of flexion and extension. Lumbar forward flexion is 75 degrees and extension is 20 degrees. Kemp’s maneuver/Facet loading is positive on the right. Straight leg raise is equivocal on the