Ime Report Sample

He underwent an interlaminar injection in May 2015 which improved his lower extremity pain by 99%. This has lasted him up until 1 month when he has had recrudescences of pain emanating from the low back radiating intermittently into the left lower extremity in a sharp shooting fashion, average pain 5/10, and worse pain 81/0. The pain is frequent and is associated with numbness and tingling. There is some difficulty with walking. Over the past 1 month, the pain has been severe. Home exercises and nonsteroidal anti-inflammatory medications (NSAIDS) have not been effective in reducing his pain and the pain is severe at times and limiting his ability to lift and sit. Walking, exercise and standing increased the pain. Lying down reduce the

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.

Based on the medical report dated 04/01/16, the patient complains of pain in the neck with radiation to bilateral upper extremities and pain to the lower back with radiation to the lower extremities with tingling/numbness and weakness. He rates his pain 8-9/10.

As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his

On examination of the cervical spine, there is tenderness and tight muscle band is noted on both the sides of the paravertebral muscles. There is pain with extension and palpation of right facets.

A review of her medical records indicates that she did have her bladder biopsy which confirmed bladder cancer. She is starting radiation therapy today with Dr. Cook. Her radiation treatments will be 5 days a week for 5 weeks. She reports that her chronic HTN is stable with medication; her opiate induced constipation is stable. She states that her bowel regimen is on hold due to her having diarrhea. She continues to take Eloquis for DVT in left leg. She is followed by Dr. Rosen for oncologist.

DOI: 8/6/2015. Patient is a 51-year-old female licensed vocational nurse who sustained a work-related injury to her back and hips while moving a client. As per OMNI, she was diagnosed with muscle spasm, pain over the low back and thoracic region. She is status post right carpal tunnel release on 02/26/16.

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

DOI: 6/23/2016. Patient is a 42-year-old female registered nurse who sustained injury to her neck/left shoulder when she twisted to keep the attachment from falling to the floor. Per OMNI, she was initially diagnosed with strain to multiple body parts.

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

The x-rays of Plaintiff’s spine showed normal alignment, no swelling, no fracture or dislocation and normal lordosis of the cervical and lumbar spine. Plaintiff’s left knee x-ray also showed no fracture or dislocation, but moderate decrease in the meduial articular joint space. Plaintiff was given a general diagnosis of neck pain, back pain, low back pain and left knee pain. Plaintiff was prescribed 3 sessions per week for 6 weeks of physical therapy.

At today's visit she is found in her room sitting in her recliner. She reports chronic, intermittent, dull, achy, lower back pain. Her current pain regimen is effective for her pain according to the facility staff. The staff reports that the patient is sleeping more hours during the day. She has increased generalized weakness. No acute distress noted this visit.

DOI: 4/13/2011. Patient is a 52-year-old male consolidator who sustained a work-related injury on 4/13/2011 after wrapping pallets. The patient was subsequently diagnosed with discogenic low back pain, lumbar facet arthropathy, and depression. Per medical report dated 5/25/2016, patient presents for re-evaluation of his low back pain. Pain has been worse over the last few days. He is having a lot of aching in the right side on his low back. He gets radiation to the right anterior leg. He feels that the leg pain has gotten worse over time. Currently, he takes tramadol extended release for pain. He takes Lexapro for depression. The medications are helpful. He tolerates them well. Pain is rated as 10/10 without medication and 6-7/10 with medication.