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Neck Pain Case Studies

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DOI: 12/10/2009. Patient is a 40-year-old male laborer who sustained a work-related injury to his left foot when he fell off a ladder while pulling off a foundation plate. Patient is diagnosed with neck sprain, thoracic sprain, lumbar disc degeneration, and left ankle and foot pain. He is status post left ankle open reduction and internal fixation on 01/24/2009 and left calcaneal fracture hardware removal on 07/31/2013.

Based on the visit note dated 12/09/15, the patient presents for follow-up of neck, lower back, and left lower extremity pain.
Patient is most bothered by persistent left ankle pain, worse with ambulation. He does utilize a cane for assistance. He has been approved for surgical consultation.
He continues to report a 50% reduction in his lower back pain as a result of undergoing epidural injection on 10/27/15. He is very happy regarding these results. He does report new symptoms of numbness in his right anterior shin, but these are not so much bothersome but just new since …show more content…
On examination, musculoskeletal strength is 4/5 with lower leg flexion and extension and ankle dorsiflexion and plantar flexion. Patient has antalgic gait.
Current medications include docuprene-sodium, Ketamine 5% cream, Protonix, glucosamine sulfate, Prozac, hydocodone-apap, Sildenafil and Wellbutrin.
Diagnoses are left foot ankle and joint pain, lumbosacral region intervertebral disc degeneration, cervical and thoracic sprain, chronic pain and pain disorder with related psychological factors.
Plan is for urology consultation due to left buttocks pain associated with erection, considering the symptoms have been consistent since his injury.
Current request is for 1 Urology Consultation between 12/28/2015 and

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