Medical Case Summary

Based on the progress report dated 03/28/16 by Dr. Bakhos, the patient presents for follow-up of his right knee

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.

DOI: 12/19/2012. Patient is a 52-year-old female laborer who sustained injury to her neck, back, and right shoulder due to motor vehicle accident. Per OMNI, she underwent an emergency neck surgery with 5 screws at C5-7 and back fusion and rod placement at T8-10.

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

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: 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.

Patient unable to walk heel to toe, perform the Romberg test, stand on one foot, or perform a shallow knee bend without risk of falling. The patient complains of lower back, hip, and knee pain. . Assessed patient’s pain at this time. Patient states that, “the pain is felt in her lower back, hips, and knees constantly and relieved with ibuprofen” she rated the pain a 4 on a scale from 0 to 10. Patient stated, “lower back always aches.” Described the pain as constant and dull. Affects her activities of daily living because she “isn’t able to cook, clean, or exercise.” In a supine position the patient, with help, was able to extend legs upwards about 40 degree and flex hips with limited range of motion. Patient was able to resist with light resistance when pressure was applied to the legs anteriorly and posteriorly. Sitting back in the patient’s chair, the patient was able to bend at the hip. No pain or tenderness felt when palpating the spinous process. The patient was able to actively flex and extend the ankle joints with limited range of motion and some resistance with support under the lower leg. The patient was able to flex and extend the feet with limited range of motion and some resistance. No pain or crepitus with flexion and extension of the feet and ankles. Inspected the patient’s skin of the anterior and posterior legs, ankles, and feet. The skin of the upper legs were dry, with

Per verification to the PT facility, IW has attended approximately 215 post-operative PT sessions for the right shoulder with last visit on

Impression includes chronic right knee pain status post anterior cruciate ligament repair and significant degenerative joint disease of the knee.

IW was assessed to be progressing slower than expected. His progress is being limited by bilateral pars fracture and long gaps in care.

Are the requests for 1 Right Thumb Spica Splint; and 18 Physical Therapy Visits for the Right Wrist between 6/17/2016 and 8/16/2016 medically necessary?

Treatment plan includes additional 6 acupuncture sessions as IW has reported 10% improvement, lumbar ESI at right L4-5, trial of Melatonin for sleep and follow-up in 4 weeks. Patient has completed 6 acupuncture visits with good benefit. She reports having fewer flare-ups after she completed acupuncture, improvement with pain symptoms and has increased range of motion and improvement in her flexibility and muscle strength.

Per verification to the PT facility, the patient has attended 4 PT sessions to the cervical/thoracic and lumbar spine, right wrist and left knee from 03/26/16 through 06/17/16. It was verified from the provider’s office that this is an initial request for chiropractic treatment.

DOI: 6/14/2009. Patient is a 56-year-old female cabin cleaner who twisted her back and sustained a right ankle inversion injury after falling forward 3 to 4 steps down the stairs. Per OMNI, patient is status post right ankle arthroscopy and peroneal tendon repair on 12/20/2009. She also had lower back pain and depression.

She was assessed to have lumbar disc herniation L4-L5, status post microdiscectomy, with recurrence and left L5 lumbar radiculopathy.