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Question
Arnold is a 49-year-old male who is having a bit of a rough year health-wise. It all started with a traumatic MVA in which he injured his back. After a lumbar laminectomy, he has gained weight and continues to have severe low back pain. He has had some limited physical therapy, but stopped showing up for appointments. A few months ago he broke his wrist. He saw occupational therapy, but missed those appointments too. Then he lost his job as an electrician. A few weeks ago, he developed a bad case of sinusitis that has not responded fully to antibiotics. He's back in the clinic today with stomach pain and diarrhea, perhaps due to the prolonged antibiotic treatment. What are the primary and secondary diagnoses if any?
Consider that an employee within a company-sponsored (OSHA required) medical monitoring program for your industry has just had an annual work physical
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