MRI Case Summary Injury

DOI: 02/27/2014. The patient is a 63-year-old male driver who sustained lower back injury while unloading foods and fell between the loading dock and rear trailer.

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.

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

DOI: 2/11/2014. This is a case of 37-year-old male production worker who sustained a work-related injury to his back when he bent over to scan the rack tracking bar. As per OMNI, he was initially diagnosed with lumbar spine sprain/strain and gastritis secondary to non-steroidal anti-inflammatory drugs. Patient is status post left-sided L4-5 discectomy on 03/11/2015.

He reports no major changes in his condition, since his last visit. His pain is rated as 3-6/10, described as dull, hard, aching or worse. Pain is increased with sitting, standing, walking, lifting, looking up and down, turning to the sides, bending, and twisting. He is unable to work. He is very limited physically. He has to modify or avoid social and recreational activities to manage the pain. He feels like his quality of life is severely affected. His pain is 80% in the neck and 20% in the upper extremities, mostly on the

DOI: 6/30/15. The patient is a 49-year-old male who sustained a work-related injury to his back due to repetitive shoveling of industrial grease. The patient was subsequently diagnosed with protrusion L3-L4, L4-L5, L5-S1, with neural encouragement and radiculopathy; lumbar myofascial pain; and anxiety and depression symptoms.

Based on the progress report dated 02/09/16, the patient presents for follow-up. He describes ongoing difficulty with pain in both shoulders, wrists, low back and the bilateral lower extremities from the knees to the calves. His symptoms include pain, spasms, numbness and tingling. He rates his pain level as a 9/10 in intensity, but it is reduced to a 7/10 with use of his medications. He reports that morphine is helping, but he is still taking 5-6 Norco a day. He is also taking a stool softener three times a day as well as Linzess. However, he continues to have significant constipation.

Based on the progress report dated 04/05/16 by Dr. Fieser, the patient complains of pain in the left knee, left ankle and left foot, associated with numbness and tingling in the left leg/foot, as well as weakness in the left leg. He describes the pain as sharp, cutting, throbbing, dull, aching, pressure-like, cramping, shooting and shocking with muscle pain and pins-and-needles sensation.

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.

DOI: 8/1/2014. Patient is a 46-year-old female relationships manager who incurred injury to her back from a horse at a camp site. As per OMNI, she was initially diagnosed with lumbar strain, thoracic strain, contusion at the low back and muscle spasm.

Based on the progress report dated 08/25/16 by Dr. Ahmed, the patient complains of left shoulder pain, neck pain, low back pain, and right ankle pain. IW have received certification for 12 visits of physical therapy to the lumbar spine and right ankle. Overall, the pain and symptoms remain the same. Patient also complains of difficulty sleeping due to

12/07/15 Progress Report described a follow-up visit. The patient continued to report adequate pain with the use of Vicodin and Flexeril. Review of utilization review report indicated that these medications were no longer certified. However, TPI trial with anesthetic has been certified. The patient noted 5/10-scale level pain in the lumbar region without radiation. He denied any side effects of the medication. Examination revealed trigger points with a jump response on palpation of the lumbar paraspinal muscles. The ROM is restricted in the lumbar region secondary topain and stiffness. Faber sign is positive on the left. SI joints are non-tender. SLR and sitting SLR are negative. Treatment plan included Vicodin and Flexeril. Work status: Return to full duty; avoid lifting > 20 lbs and frequent bending activities.

Based on the medical report dated 07/14/16, the patient complains of pain and discomforted all the time. Patient states, “It gets worse longer I remain sitting and with any time of movement that requires my back muscles to work, it is very painful and uncomfortable.” The patient complains of constant moderate to 6/10 sharp, stabbing low back pain radiating to left leg with numbness, tingling and weakness.

DOI: 7/15/2003. Patient is a 73-year-old retired male central services employee who sustained a work-related injury to his back while he was pushing heavy cart. As per OMNI, the patient was diagnosed with back strain.