User:Saltrabook/Structure of the OM Patient Record

PATIENT RECORD EXAMPLE:
INTRODUCTION

A 56- year-old man, a machinist referred from Injuries to the specialist's certificate due to a notified disease is osteoarthritis. The disorder is notified on 10.01.2008 due to congestive Shoulder impingement. The effect described, in the case of repeated heavy lifting in 1982 , and the symptoms started around 2007. Has worked for many years with heavy lifting daily for height corresponding to the chest at a lathe in the workshop.

ALLERGIES

None known.  PREVIOUS DISEASES

Has almost always been healthy until the present, not in hospital.

FAMILY DISEASES

No osteoarthritis or other ailments in general.

WORK HISTORY

Completed schooling in 1973 after the 9th grade.

1973-1979 trained as a machinist and then continue as an employee of Korsor prop, Norvangen 12 in Korsor that manufactures marine equipment.

1979-1982 as a skilled worker by Evopan ( closed).

1982-2007 as a machinist at Korsor prop, which manufactures marine equipment.

Postponements at work on Korsor Propeller : Was busy most of the time with work at the lathe and workshop. Manufacture of propellers, mainly up to 17-18 inches in diameter, where he could produce up to 30 pieces per day. It is that he picks the items on the material warehouse and run them on the hand truck into the lathe, where he promises piece in place with both hands so that the left arm in a horizontal static grip while he mounts the pieces. The number of propellers he performed variede to a few and up to 30 pieces a day. It is estimated that he used between half and 75% of working for the manufacture of propellers. The rest of working, he has used for other smaller or larger tasks lathe. In any case, he has used the same method to the subjects lifted into place and held with left arm raised to approx. 90 ° away from the body in a static grip. He estimates that he throughout the working hours used 50-75 % of working together in all the years as a machinist at this company. Social consequences : Current condition started around 2007 and reported as an occupational disease in 2008. He has been sick pretty much most of the time from 2007 until retirement in 2012 when after 2 working tests determined that he receives a disability pension. Has been in rehabilitation. This has had the impact that he has had difficulty sleeping at night because of pain and could not even make the ordinary everyday things in the home. Currently, he can not even mow. The economic impact has been that moment. has been on sick pay from 2007 to the granting of early retirement in 2012. Has been awarded a pension from the industry's Pension, which assessed that his work is reduced to 2 / 3rd The same goes for his own retirement, Danica, who has also been his earning capacity to be reduced to 2 / 3rd Due. pain in the shoulder had to give up fishing and hunting.

Work from 1982-2007, did have 25th anniversary at Korsor Propeller. Worked as described by the rotation of the propeller, which has accounted for between 50% to 75 % of his working time. Have involved exertion of both the left shoulder and upper arm, but also on the right. As described were used large muscle strength by lifting and static fixation of the issues when installing the lathe. Moreover, when he must use the key to tighten the subject and fraspænde items in the lathe, use excessive force with both left and right hand. This work has led to repeated work movements throughout the workday. Both the manufacture of the propeller, but also to production of other , ie. of the working week actually. Worked involved awkward posture / movement of the shoulders and upper arms ? Yes it has it because he knows both retention of subjects and tightening these and dismantling of these have used the turning and twisting movements of both right and left arm. This has been true for 25 years, and in virtually all of the working day, with the exception of the time that has been used to retrieve the items and to keep them in place in the boxes. This means that the awkward postures and repetitive work movements have been at least 80% of working time throughout the year. Is the shoulder has been moved forwards / upwards ? - Well, the shoulders have been brought forward and upward, as described in the assembly and dismantling of the items in the lathe. Worked led to repeated lifting of the upper arms ? - Yes, it has, in the same way as described. Worked resulted in static lifting of the upper arm ? - Yes, it has, as described by application and removal of the items. Worked led to other significant loads? There were other significant loads, among others, the neck muscles , which he developed pain in regularly , at times constant. The approximate cycle time of each job, estimated cycle time has been such that he has used from 5-10 min. with the static movements, and then have even machining if desired lasted 10-15 min. , virtually repeated throughout the day.

PRE- EXISTING DISEASES

Pt. have not been exposed to other illnesses or injuries that might affect the shoulder loads or disorders of the shoulder. There have been no frozen shoulder, no changes in the spine radiating to the shoulder joint, no precipitation of calcium in the rotator cuff tendons, and no osteoarthritis of arthrosis humeri scapularis detected a slight arthrosis of acromioclavicularis.

INDIVIDUAL ASSESSMENT OF WORK LOADS

The described work is labor-intensive processes in metallurgy, as even though the pt is strong built, has been exceptional loads.

DISEASE COURSE

The symptoms started in early 2007 without there having been any special loads, but as part of their daily work. Debuting with stress -related pain in the left shoulder and arm. He was forced to offload the right shoulder and arm and then he also got symptoms on the right side. Physiotherapy had no good effect, only worsening the condition. 2008 Holbæk Hospital, surgery on the left shoulder , repeated the same year and again 2009. Is surgery on his right shoulder in 2010 at Bispebjerg Hospital and the second time in 2011 the same place. He has also been examined by a specialist Otto Bangkok in 2008 and with Peter Lavard in 2010. Neither physiotherapy or operations in the shoulders have had a particularly good effect. The diagnoses raya Hospital, Orthopaedic Surgery Outpatient Surgery is arthrosis primaria in other joints on the left side and shoulder disorder, unspecified. Have gone to physiotherapy rehabilitation in the process, but without good effect. Does not that have been particularly good effect on the operations of the shoulders, to some extent on the right side. The diagnoses raya Hospital, Orthopaedic Surgery Outpatient Surgery is arthrosis primaria in other joints on the left side and shoulder disorder, unspecified. The diagnoses from Bispebjerg Hospital is laesio traumaticae tendinitis deltoidei ( rotator cuff, right-sided ) and afklemningssyndrom in the shoulder and arthrosis posttraumaticae in other joints. The diagnoses from Bispebjerg Hospital is laesio traumaticae tendinitis deltoidei ( rotator cuff, right-sided ) and afklemningssyndrom in the shoulder and arthrosis posttraumaticae in other joints. The current complaint is that he can not carry too many things at home without being able to look forward to a sleepless night because of the pain. These are impairments in virtually all the daily functions where he should meet for help from the family. Mention also that he was due to downturn in the economy had to buy an older car, where there was no power steering , which meant that he could not actually drive the car , and was again going to get a smaller car with power steering. STRICT On both skuldreled found decreased mobility and decreased muscle development. There is pain and tenderness on palpation of the front of the shoulder joint, no positive pain or drop arm. There are squeezing phenomenon by inward rotation when the arm is held horizontally in 40 ° abduction with their hands. The most pronounced on the left side, but also on the right side. In general, simply by lifting the lever up to more than 45 ° away from the body. Movement : On the left side, he can keep his arm up to approx. 120 ° , set up inward and outward rotation of approx. half and extension and flexion of the shoulder joint is also reduced to approx. half. On the right side is the movement of the shoulder joint is not so much reduced, but to approx. 75 % of the full. Muscular : There is clearly muscular dystrophy on both bicepsmuskulaturer, the scale on the left side is 33 cm and 31 cm on the right side. He previously had much muscle development on both sides. At the forearm measures muskelfylden at its thickest point and 27 cm on the right side 26 cm. There is direct tenderness on pressure equal to subacromial bursitis and tenderness of the biceps tendon at the shoulder front surface on both sides. Sulcustest negative on both sides. Pt. are right-handed, your fingers can move freely and can be on both sides attached to the palm. There are normal movement of both wrists, on the right side scars after surgery for carpal tunnel syndrome. Muscular : On the left shoulder is seen clearly flattening of the deltoid muscle, greatest extent of the upper arm is 33 cm and 27 cm on the forearm. There are good muscle development of hand muscles on both sides. There are good circuit with clear pulse on both radial artery and no trophic disturbances.

SUMMARY

56- year-old man, a machinist referred from Injuries to the specialist's certificate for a shoulder ailment. Is previously healthy. Professionally, he has been a mechanic for 25 years in the manufacture of propellers for ships of engineering. Has worked with lathe approx. 80% of working with lifting heavy pieces of material up to 15-20 kg. There was a recurrent repetive movements by attaching or removing heavy objects in the lathe. Left shoulder is moved upwards and forward over your shoulder and keep the items with a static grip. Symptoms debuted around 2007 in the left shoulder. When he overloads the right shoulder to relieve the left arise like symptoms on the right side. Is surgery on his left shoulder 2 time in 2008 and in 2009. Moreover surgery on his right shoulder in 2010 and 2 in 2011 also at Bispebjerg Hospital. Is also studied in medical specialists Otto Adelaide in 2008 and Peter Lavard in 2010. Have gone to physiotherapy rehabilitation in the process, but without good effect. Shoulder operations have not had any good effect to some extent on the right side. The diagnoses raya Hospital, Orthopaedic Surgery Outpatient Surgery is arthrosis primaria in other joints on the left side and shoulder disorder, unspecified. The diagnoses from Bispebjerg Hospital is laesio traumaticae tendinitis deltoidei ( rotator cuff, right-sided ) and afklemningssyndrom in the shoulder and arthrosis posttraumaticae in other joints. Got awarded health -related early retirement in 2012. Objectively decreased mobility of woe. shoulder joint to less than half and about 1/3 set up on the right side. There is pain and tenderness on palpation of the front of the left shoulder, a positive pain and drop arm test. There is a distinct muscular atrophy of both biceps and tenderness of the biceps tendon at the shoulder front surface.

DIAGNOSIS

/ DM75.1 Rotator cuff syndrome

DM19.0 Arthrosis of the Acromio-clavicular DZ57.8 Occupational exposure to other risk factors /

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