Patient File - Lonnie Burch

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CLINICAL RECORD FORM

ADMINISTRATIVE & SELF-REPORT INFORMATION (May Be Completed by Patient)

Patient: Lawrence William Christopher Burch III Date of Birth: 03/15/2002 Age:17

Employer/School: Cobalt Hill

Sex: Male Marital Status: Single
Current Medical Conditions: None reported.
Current Medications, Herbal Supplements & Vitamins (Daily Dose, Start Date, Name of Prescriber): None reported.

Primary Care Physician Name: James Mallory

Reason for Seeking Evaluation Today: The patient admitted with muscle pain, soreness, and general upper body weakness, after an intense training exercise meant to push the upper limits of his powers. Patient normally can negate the matter/mass relationship of up to one (1) standard imperial ton. Patient claims to have been able to handle one (1) and a half tons, but blacked out after trying more.



Presenting Problem: A strain to the muscle and muscle tendon equivalent of a sprain to ligaments occurred at trapezius, deltoid, and latissimus dorsi muscle grouping showing a Grade II (moderate) strain with half of involved muscle fibers torn. Acute and significant pain is accompanied by swelling and a minor decrease in muscle strength. Muscle strain occurred when these muscle fibers could not cope with the demands placed on them by exercise overload and which led to a tearing of the fibers. It is a contraction-induced injury in which muscle fibers tear due to extensive mechanical stress.

Past and Present Use of Cigarettes, Alcohol and Other Substances (Date of First Use, Most Recent Use, Use in
Past 3 Months; Legal, Vocational and Family Consequences): Patient smokes Newports, has consumed more than one beer within last 3 days, patients smoked marijuana.
Treatment Plan
Specific Target Sx/Behaviors: None Interventions (Related to Goals):None Estimated Time for resolution: 2/3 weeks

Patient suggested to apply soft padding to minimize impact with objects. Rest to accelerate healing and reduce the potential for re-injury. Apply ice to induce vasoconstriction, which will reduce blood flow to the site of injury. Never ice for more than 20 minutes at a time. Wrap the strained area with a soft-wrapped bandage to reduce further diapedesis and promote lymphatic drainage. Keep the strained area as close to the level of the heart as is possible in order to promote venous blood return to the systemic circulation.

NSAIDs such as Ibuprofen/paracetamol work to reduce the immediate inflammation.

After 2 or 3 weeks of injury, tension should be applied in the line of normal stresses for proper remodeling anatomically and functionally.