Mid Back Injury

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This is a 30-year-old female with a 6/19/2015 date of injury. Boxes fell on her, as she was she was trying to make room in the freezer.

DIAGNOSIS: Strain of muscle, fascia and tendon of lower back, S30.012A, Strain of muscle and tendon of front wall of thorax

12/16/15 Progress Report described that the patient has mid back thoracic pain. VAS score was 8/10. The pain is constant and moderate in intensity. The pain has tingling and numbness. It is aching and sharp. Activity aggravates it and rest improves it. The patient is able to perform her ADL. The exam of the lower back revealed reduced ROM in the thoracic spine. There is tenderness to palpation in the para-spinal region at the thoracolumbar junction. There are reduced sensations to cold. There is pending thoracic MRI. Treatment plan included a trial of Medrol Dosepak, Topiramate for neuropathic pain refractory to gabapentin, request for TENS unit and PT. …show more content…
There was some radiculitis or radicular-type symptoms in the mid back. Exam revealed point tenderness from T4 down to about T7. Extension of the spine reproduced pain in the mid portion of the back. Treatment plan included CBC differential, MRI thoracic spine, continue Tylenol and thermacare patch. Follow-up was in 1 week. Work capacity had changed to 5 pounds of lifting; pushing and pulling; sitting and standing as able and for 4 hours per

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