Dr. Livermore's Case Summary

Range of motion shows flexion of 85 degrees, extension of 30 degrees, and lateral tilt of 25 degrees bilaterally. Straight leg raise is positive on the right at 90 degrees for low back pain. Bechterew's test is positive on the right. The patient has diminished sensation in the right L4, L5 and S1 dermatomes. Deep tendon reflexes are absent in the right knee and right ankle.

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

-Contacted Desert Springs facility and follow-up on the patient. Spoke to medtech Muriel and stated that another caregiver has been going to patient’s room and no complaint or concern was raised from the patient. Instructed Muriel to see the patient and she stated that patient is the same and “normal” sitting up in her recliner’s chair. Speech is clear and no facial droop per Muriel. Per Muriel, patient did complaint about a week ago with right foot

Physical therapy saw the patient, and the result of the examination are as follows; 6/10 left knee pain at rest and during activity (0 no pain, 10 worst pain), manual muscle testing for both upper and lower extremities were 4/5 except left knee flexion/extension 3+/5 due to pain, sensation on both UE/LE were intact to light touch, Stephen requires a moderate assistance of one person for both functional mobility and gait activity. He uses a front wheeled walker up to 35 feet due to decreased balance and antalgic gait from the left knee

The patient stated that overall the symptoms have decreased. Antalgic gait has improved. The pain is decreased but it increases in the morning. The patient reported pain 3/10-scale level. Rom and Muscle strength remained the same. Swelling has decreased. Tenderness to palpation in the lateral and medial malleolus decreased. Muscle testing plantar flexion remains weak. Dorsiflexion remains weak. Review of Systems revealed joint swelling and loss of bladder/bowel control. Treatment plan included PT

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

As per office notes dated 5/4/16, the patient is seen for bilateral elbow pain and bilateral wrist pain. She rates the pain as 3/10 with medication and 7/10 without medication. She is active for at least six hours a day and has energy to make plans. Her activity level has

Based on the medical report dated 03/31/16 by Dr. Schonwald, the patient reports pain in his low back, left lower extremity, right lower extremity, as well as in his left hand that originates at his left elbow and to his fingertips.

On Primary Treating Physician’s Progress Report (PR-2) dated 08/11/2017, the patient presented with unchanged symptoms. His left-hand pain was rated at 8/10. and was described as constant and sharp. The pain was aggravated with certain movements and gripping. The

Per the IME report on 4/28/16 by Dr. Pierce Ferriter, the patient reports that he is actively treating with physical therapy and chiropractic treatment at a frequency of 3 to 4 times per week. The patient’s diagnoses include resolved lumbar strain, resolved cervical strain, resolved left shoulder strain and resolved right knee strain. There is no medical necessity for further physical therapy, orthopedic treatment of diagnostic testing based on examination.

DOI: 1/29/2012. Patient is a 34-year-old female clinical assistant who sustained a work-related injury to her back when she was transferring a patient and felt pain in her low back and left side. She has prior history of lumbar laminectomy. She was treated conservatively with non-steroidal anti-inflammatory drugs, physical therapy and work restrictions. Per the PT progress notes dated 10/29/14, patient has attended 21 sessions for the back. She is status post left sacroiliac joint and left piriformis trigger point injection on 08/27/15.

Review of diagnostic studies and medical-legal reports is included in the physician’s notes. Objective findings note that the patient is mildly obese and appears to be in moderate pain. He does not show signs of intoxication or withdrawal. His gait is antalgic gait and is assisted by cane. Lumbar range of motion is restricted with 50 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral bending, and 10 degrees of left lateral bending. All range of motion is limited by pain. There is tenderness noted in the bilateral paravertebral muscles. Lumbar facet loading is positive on the left side. Ankle jerk is ¼ on the right and 2/4 on the left. Patellar jerk is ¼ on the right side and 2/4 on the left side. There is tenderness noted over the trochanter and pain to the lateral hip with range of motion. Right side motor strength of ankle dorsi flexor is 4/5 and ankle plantar flexor is 4/5. Hip flexor is 5-/5. Light touch sensation is decreased over the lateral calf on the left. Patient has resting tremor of the left lower extremity. His medications are Prilosec 20mg, Celebrex 200mg, Neurontin 800mg, Flexeril 10mg, Duragesic 75mcg/hour patch, Viagra 100mg, Nuvigil 150mg, and Silenor 6mg, Evzio 0.4 mg, and Norco

Based on the medical report dated 01/03/17, the patient presents for pain/dysfunction of the right wrist. IW states repetitive heavy lifting and complains of numbness, tinging and weakness.

Office notes dated 06/21/2016 revealed that the patient complained of right foot pain with a pain rating of 6/10. Physical examination revealed tenderness

Pain score was 7/10 at rest and increased on movement; blood pressure was normotensive 130/90; mean arterial pressure [MAP] was 100; heart rate was 85 beats per minute and rhythm was regular; respiratory rate was 16 breaths per minute and spontaneous; body temperature was 36 degrees C; oxygen saturation was 99% on own air; GCS 15/15; blood glucose level was 6.5 mmol/l. Physically unstable patient [PUP] score zero. Patient was received upright in bed with knees contracted up and was exhibiting facial grimacing. Suprapubic tenderness and