Lombar Injury Report

Blood pressure -138/88, HR 71, Lung sounds –clear, temperature 98.8 F, radial pulse and pedal pulses +1 bi-laterally, normoactive bowel sounds. No history of smoking, drugs, alcohol use or diabetes; takes no daily medications. Surgical history: Hernia surgery September 2016 and cataract surgery September 2013. Moderately active, walks every day, sometime incorporating hand weights. Patient presents with minimal trembling unilaterally, (left side) when fingers stretched out, reports movements have been slower than normal. Patient’s wife reports “He’s been eating more slowly and it has been taking longer for him to get dressed in the morning.”. Upon examination it was determined that patient has reduced arm swing, slight stiffness in neck, difficulty rising from sitting position in the chair, masked facial features and deteriorated balance. No signs or symptoms of stroke.

Acetaminophen 500 mg tab 1 tab 1 tab by moth every 6 to 8 hours as needed for pain

Acetaminophen (Tylenol). The resident takes Tylenol around the clock (ATC) for pain which is within the recommended dose of 325-650 milligrams every

OI: 11/22/2009. Patient is a 46-year-old female certified nursing assistant who sustained a work-related injury to her low back while helping move/lift a patient. Per OMNI, the patient is diagnosed with status post lumbar laminectomy surgery on 07/26/10, lumbar degenerative disc disease, and lumbar radiculopathy. She was deemed to have reached permanent and stationary status by PQME Dr. Well last 12/01/11.

She had to take a neurological examination in which, she had absent abdominal reflexes with brisk tendon jerks and bilateral extensor plantar responses. Blood investigations

Based on the latest medical report dated 10/6/16 by Dr. Simhaee, the patient has been having low back pain. The pain in his back is a constant ache with a burning sensation, which he rates an 8/10. The pain

Continue with Acetaminophen 500 mg tab, 1 tab by mouth every 6 hours as needed for pain X 1 weeks

He was given a refill the prescription for Flexeril 10 mg #90 one tablet three times daily as needed, muscle relaxer with three refills and Motrin 800 mg #60 one tablet twice daily for inflammation with three refills.

DOI: 07/07/2008. This is a 56-year-old male machine operator who sustained a work-related injury to his lumbar spine as a result of being hit on the left side of his leg by a corrugated sheet and twisted his lower back. Patient is diagnosed with lumbar spine neuritis, sciatica, and sprain of the sacroiliac ligament. He is status post lumbar discectomy on 02/28/2011.

DOI: 8/14/2015. Patient is a 25-year-old male security officer who sustained injury while he was running for a code gray when he felt pain in his back. Per OMNI, he was initially diagnosed with disc protrusion and radiculopathy at L4-5. Patient has reached maximum medical improvement (MMI) and P & S on 12/01/15 by Dr. Saucedo with future medical care of PT, pharmacotherapy, physician care and diagnostic studies.

Musculoskeletal The patient has right sided weakness on upper and lower extremities related to her stroke. Right sided weakness prevalent on range of motion exercises, mobility and strength is limited. Left sided range of motion was completed while the patient was sitting bedside, she was able to complete range of motion by lifting left leg, bending left knee and flexing the left foot without difficulty. The patient is unsteady, weak and is unable to stand or transfer on her own, so I was unable to perform the Romberg test, assess gait, heel to toe walking, standing on one foot, or shallow knee bend. I observed the patient’s spine with the client touching her toes from a sitting position at the edge of the bed, spine is straight, with

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.

The patient reported a 25-year history of intermittent low back pain since an initial fall in 1990 with exacerbation of symptoms upon aggravation of the patient’s comorbidities, or with an extreme decrease in activity. The patient’s medical history also included fibromyalgia, lumbar osteoarthritis, irritable bowel syndrome (IBS) and bilateral neuromas between metatarsals 2-3. The patient underwent an ileostomy 3 years prior, secondary to the IBS. The patient noticed onset of the bilateral lower extremity radicular symptoms after she slipped and fell on her wet garage floor, landing in a sitting position, 5 weeks prior to her physical therapy initial evaluation. As a result, she was experiencing constant sharp/shooting symptoms coupled with functional limitations including sitting, standing, walking, ascending/descending stairs, transfers, bending, and lying down, making it difficult for her to sustain any one position for any significant period of time. Consequently, the patient found herself significantly limited in her ability to complete her activities of daily living (ADLs). Using the Numeric Pain Rating Scale (NPRS), the patient rated her current pain level as 6/10 at best and 9/10 at worst. The patient stated that her physician had

Aleve, Naprosyn, ibuprofen, and she complains of gastrointestinal upset from NSAIDs. The patient also has herbal topical analgesics for knee pain. It was noted further that the patient failed the trial for Norco 5/325 mg due to gastrointestinal upset. Soma is also discontinued. It was noted as well that the Voltaren gel is helping more than the Lidocaine ointment. The patient has allergies to sulfa drugs, aspirin, penicillin, and Fosamax. The 4 A’s of pain management is reviewed and notes that the pain is reduced to a tolerable level; activities of daily living are better/able to exercise/do house chores and laundry; denies any side effects; and that the patient is taking the medication as directed. Lumbar spine examination revealed that there is diffuse tenderness to palpation over the midline at L3-S1; diffuse bilateral tenderness at the lumbosacral paraspinal region at L3-S1; and diffuse tenderness with tightness over the thoracolumbar paraspinal muscle approximately from the T9 down to the L2 level as estimated by the provider. There is myofascial tenderness and tightness over the paraspinal

The claimant’s motor movement appears appropriate, congruent with his visual coordination. He appears to exhibit no noticeable physical discomfort during the evaluation. His manual dexterity appears normal and there were no signs of tics or tremors. He appears to display mental fatigue.