Gastrointestinal Injury: A Case Study

DOI: 09/12/2014. Patient is a 45-year-old male vacation relief route sales representative who sustained a work-related injury to his lumbar spine from bending and pulling a bread product. Per OMNI entry, he was initially diagnosed with disc herniation at L4 to L5 with radiculopathy. He is status post extraforaminal L4 to L5 discectomy on 04/09/2015. He has been off work for nearly 2 years.

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.

DOI: 7/7/2015. The patient is a 48-year-old male cleaner who sustained a work-related injury to his back while moving a heavy bookcase. As per OMNI, the patient was diagnosed with lumbar degeneration, thoracic or lumbosacral neuritis and myofascial pain.

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

DOI: 12/3/2012. The patient is a 49-year-old male route sales representative who sustained a work-related injury to his lumbar spine and shoulders while lifting a bread rack out of his truck. Patient is status post bilateral L4-5 laminotomy, complete facetectomy and foraminotomy on 01/14/15.

DOI: 11/24/2011. The patient is a 48-year-old female home health aide who sustained injury while turning a patient in bed to put a clean pad when the bed moved. Per OMNI, the patient is diagnosed with L4-5 disc herniation with annular tear and left knee radicular syndrome. She has undergone posterolateral and interbody fusion at L4-5 on 02/18/2013.

The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.

Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

DOI: 12/23/2013. The patient is a 64-year-old male foreman who sustained injury when he was involved in a motor vehicular accident. Per OMNI, he has had multiple injuries to the right shoulder, right knee, back and right arm/elbow. He is status post arthroscopic surgery for the right shoulder on 05/30/2014.

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.

DOI: 09/18/2012. Patient is a 59-year-old male truck driver who sustained injury to his head, left eye, ribs, lungs, shoulder, and back when he lost balance and fell while he was removing tarp at an ecology sample area. Per OMNI entry, he was initially diagnosed with punctured lung and 2 fracture of the lumbar discs. Patient is status pots L4-5 discectomy on 02/27/16 and L4-5 posterior pedicle screw fixation on 06/26/13. Per Ortho AME Dr. Ovadia, IW‘s shoulder is not P & S. Neuro AME Dr. Wang opined that the IW has 10% whole person impairment rating on 09/22/16.

DOI: 5/13/2014. The patient is a 29-year old female manufacturing lead who sustained a work-related injury to her back when she was lifting two ostellation trays which weigh about 30 pounds.

Objective Functional Improvement shows that the patient is now able to get dressed with minimum assist. He is also now able to navigate 2 flights of stairs without pain, same as prior, now able to walk for 8 minutes, same as prior, can now lift 6.5 lbs. of weight, improved from prior, and push 6 lbs. of weight, same as prior. Therapy goals for this patient in the next 4 weeks are to reduce inflammation from moderate to minimal and increase cervical and lumbar spine flexion and bilateral rotation by 3 degrees. The patient in the next 4 weeks will be able to get dressed easier, navigate 2.5 flights of stairs without pain, walk 9 minutes from 8 minutes, lift 7 lbs. of weight, and push 7 lbs. of

DOI: 05/07/1980. The patient is a 73-year-old male foreman who sustained a work-related injury to his lumbosacral spine, left knee, and right heel when a pile of lumbar fell on him. Patient is diagnosed with lumbar post laminectomy syndrome, foot drop, and non-union fracture. He has a history of hypertension and diabetes. He is status post 3 back surgeries, laminectomy at L4 to S1 in 1973, bilateral decompression laminectomy and discectomy at L4 to S1 in 1981, and 2-level fusion with failed fusion in 1991.