LOCATION: Outpatient, Rehabilitation Clinic PATIENT: Jason Tunic ATTENDING PHYSICIAN: Frank Gaul, M.D. CONSULTANT: Mary Barneswell, M.D. Jason is a 34-year-old male was referred to complete a disability assessment. He did receive physical therapy services, although has been discharged at this time. At this time, he reports he has chronic pain in his low back region. OBJECTIVE: The client’s activity abilities on this date are as follows: Bending: unable to without discomfort. Twisting is very painful. Kneeling: 2 minutes constantly, with troubles getting up and down. Standing, walking and sitting: 10 minutes constantly. ASSESSMENT: Overall, the client does demonstrate cooperative behavior. Performance was consistent among test items. Initial and final pain level was 6 out of 10. PLAN: The client will continue with the prescribed recommendation from primary physician along with further therapy. The client will be seeing his doctor on this date for re-evaluation. Thank you for the opportunity to evaluate this patient. If I could be of further assistance, please contact me. DIAGNOSIS: Work-related low back injury due to heavy lifting. CPT, HCPCS, ICD
This essay discusses the assessment and management of Jason Tunic, a 34-year-old male who presented at an outpatient rehabilitation clinic with chronic low back pain. Jason’s condition is assessed, and the objective findings, assessment, plan, and diagnosis are discussed in detail. The objective of this report is to provide a comprehensive overview of Jason’s condition, including his activity abilities, pain levels, and the plan for his ongoing care.
On the day of assessment, Jason’s activity abilities were evaluated. The following objective findings were documented:
1. Bending:Jason reported that he was unable to bend without discomfort. This suggests a limitation in his lumbar spine’s flexibility and a significant source of his pain.
2. Twisting: Twisting was noted to be very painful for Jason. This finding indicates that rotational movements may exacerbate his low back pain.
3. Kneeling:Jason could only kneel for 2 minutes constantly and experienced difficulties getting up and down. This limitation suggests impaired mobility and discomfort associated with weight-bearing on his knees.
4. Standing, Walking, and Sitting: Jason could only stand, walk, and sit for 10 minutes constantly. Prolonged periods of these activities likely increase his pain and discomfort.
Jason demonstrated cooperative behavior during the assessment, and his performance was consistent among various test items. His initial and final reported pain levels were 6 out of 10, indicating that he experiences moderate pain during the evaluated activities.
The plan for Jason’s care includes continuing with the prescribed recommendations from his primary physician. Additionally, further therapy is recommended to address his chronic low back pain and limitations in daily activities. Jason is scheduled to see his doctor for re-evaluation on this date, which suggests ongoing monitoring and adjustments to his treatment plan as needed.
Jason’s diagnosis is a work-related low back injury attributed to heavy lifting. This diagnosis highlights the physical demands of his job that likely contributed to his condition.
The assessment and management of work-related low back injuries, such as Jason’s, require a comprehensive approach that considers the patient’s activity abilities, pain levels, and limitations. By collaborating with healthcare professionals, including primary physicians and therapists, individuals like Jason can receive appropriate care and therapy to address their specific needs and work toward recovery and improved quality of life. Ongoing evaluation and adjustments to the treatment plan are essential components of managing chronic pain and functional limitations related to low back injuries.
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