Work Related Trauma Case Study
DOI: 7/2/2010. The patient is a 57 year old female claims examiner who sustained a work related
cumulative trauma injury to multiple body parts that include head/cervical spine, shoulders, arms
knees, and left hip. As per progress report dated 7/11/16, the patient reports neck and low back
pain. IT was noted that the painis associated with left lower extremity numbness, tingling, and
weakness. The patient has tried and failed multiple anti inflammatories, which causes
gastrointestinal upset, except for Celebrex. Her psychiatrist, Dr. Nehoryan has recommended her
current regimen including Cymbalta and Restoril intermittently for sleep. It was mentioned that the
patient had a fall in early 2/2016 due to left lower extremity numbness and is continuing... Show
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Conservative treatment notes included aquatic physical therapy, acupuncture, narcotic pain
medications, Transcutaneous electrical nerve stimulation (TENS or TNS), psychologist, and
hypnosis. The patient also has tried and failed multiple over the counter and prescription remedies
for her opioid induced constipation including diet modification, stool softeners, and laxatives
including Miralax, Senokot, Metamucil. Ducalax. It was noted that Movantik is being provided to
help her with this situation. As per interval changes, the patient complains of ongoing neck and left
upper extremity pain, and an increase in low back and left lower extremity pain. Patient states that
she fell at home 2 weeks ago. She states that she injured her right arm and it has been swollen for 2
weeks. The pain score is 10 without medications and 2 with medications. The medications
prescribed are keeping the patient functional, allowing for increased mobility, and tolerance of
activities of daily living, and home exercises. Current medications incldue Nucynta, Percocet,
Restoril as necessary for insomnia, Cymbalta, Neurontin, Cselebrex, Robaxin, Prilosec, Singulair,
Vagifem, and
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