Stabbed in r & l forearm and l. hand
4 months after assault: Experienced chronic pain in the r. forearm region, constant, rather severe pain over the lateral and ventral surface of the r. forearm. Increased with touch. Some problems lifting heavy objects due to pain. No other pain related to assault. Trying nonsteroidal anti-inflamitory agents with no relief.
Physical Exam: strength is 5/5 throughout upper extremities. Dminished sensation in r. lateral cutaneous nerve of r. forearm. Some allodynia to touch in that region. Tinels sign over scar in r. forearm. Diminished reflexes in the r. upper extremity.
Notes patient has marked difficulty secondary to her depression and complicated ?, and anxiety. Difficulty concentrating, low mood, low energy. (Since, April 20, 2010)
-Marked loss of concentration, even simple instructions.
-Marked loss of punctuality and ability to maintain a schedule
-Marked loss of ability to complete a normal workday
-Marked loss of ability to interact with others
No apparent distress, 5/5 strength in both lower extremities, normal gait.
Pain in lower back and left knee. Pain radiates through the lef and soreness over the medial aspect of the left knee. On Examination: tenderness over the medial aspect of the knee.
Documents: Loss of appetite, suicidal ideation, depressed mood, sleep disturbances
Dx: Major Depression, recurrent; PTSD
Goals: Alleviate self-harming impulses and return to highest level of previous daily fx
s/p debridement of r. tennis elbow 8 days. Incision well healed, pain with motion of elbow, no strength until sees her back 6-8 week point.
Sever left knee pain (10/10), dx as degenerative joint disease
Normal EMG & NCS
R. hand numbness/pain for a few years following stabbing in the forearm w/worseing symptoms for 8 months following fall down stairs.
Impression: Minimally abnormal electrodiagnostic exam
Ms. Savoy is concerned about worsening mood problems in light of severe house stressor including concerns about self harm. Concerned about her ability to work at this time.