Ortho Agreed Medical System: A Case Study

DOI: 2/8/2016. Patient is a 54-year old male laborer who sustained a work related injury/ fractured 3 ribs & back when he got stuck and fell on his left side against the concrete when he was operating jack hammer. The patient is subsequently diagnosed with Herniation of lumbar disc. As per workers’ compensation follow up dated 7/25/16, patient complains of low back and radiating pain. In the evaluation there was an S1 distribution with weakness that was quite significant. Of note, the test of the MRI scan revealed that L5/S1 had a broad-based disc bulge of 3.5 mm, bilateral facet arthropathy, and at L4/5 there is also a broad-based concentric bulge. Physical examination revealed that he is still having pain in the back going down into the buttock. It is not an acute radicular event.

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

MRI of the lumbar spine performed on 10/30/14 demonstrated mild anterolisthesis and prominent degenerative changes at L4-5, resulting in contact and possible impingement upon passing L5 nerve roots bilaterally. There is moderate bilateral facet arthropathy at this level. Mild central canal narrowing is seen at L4-5. Mild chronic compression deformity, superior endplate of T12 is seen.

CT scan of the cervical spine dated 01/07/14 revealed posterior fusion from C5 through C7. There is minimal anterior subluxation of C6 on C7.

Patient was encouraged to continue with heat, followed by his home exercise program and ice. He will continue with his transcutaneous electrical nerve unit (TENS). Patient was given an ice pack to use, to reduce pain. He was given a 60 mg Toradol injection on this visit.

Komblatt, the patient underwent extensive chiropractic treatment with 87 sessions from 10/07/11 through 07/11/12. It was opined that it does appear that the IW ha s undergone excessive passive-chiropractic treatment referable to both lumbar spine and right shoulder. It was further opined that the IW has reached MMI regarding the lumbosacral strain and contusion of the right shoulder within approximately 6-8 weeks post injury. Appropriate treatment would have consisted of aggressive right shoulder and low back rehabilitation to include aerobic conditioning, strengthening exercises involving the right upper extremity, lumbar spine and core, and resumption of normal recreational and work activities within 6-8

Based on the medical report dated 12/22/16, the patient was last seen on 10/13/16, and was recommended to have continued therapy. He has not had therapy secondary to insurance issues over the last month or so. He presents with ongoing right elbow pain status post cubital tunnel release and medial epicondylitis debridement, worsening with motion and activity, lifting, reaching, bending, upper extremity dressing, household

Based on the medical report dated 03/31/16 by Dr. Schonwald, the patient reports pain in his low back, left lower extremity, right lower extremity, as well as in his left hand that originates at his left elbow and to his fingertips.

DOI: 9/11/2001. Patient is a 47-year-old female correspondence reader who sustained a work-related injury while evacuating when she was pushed and fell in chaos due to an event. Per OMNI, she was diagnosed with herniated lumbar disc. It was noted that the patient has had

Patient underwent a posterolateral fusion, segmental pedicle fixation and lumbar laminectomy at L4-5, with facetectomy, foraminotomy and discectomy per operative report dated 03/24/15.

DOI: 5/1/2009. Patient is a 58-year-old male truck driver who sustained a work-related injury while he was on top of a load to loosen strap, when he lost his balance and suddenly jerked. As per OMNI entry, he underwent L4-L5 lumbar fusion with hardware on 3/28/2011, screw removal on 4/7/2011 and removal of hardware at L4-5, with inspection of fusion mass and revision of posterior spinal fusion on 04/22/13.

Per the medical report dated 09/08/16 by Dr. Livermore, the patient has worsening pain over the left leg, numbness of the left foot and weakness in the left leg.

DOI: 3/3/2009. Patient is a 57-year old female home attendant who suffered laceration to her right hand when she slipped/fell on sidewalk. She underwent L4-5 and L5-S1 anterior/posterior lumbar fusion on 10/20/2012.

IW was diagnosed with status post right shoulder rotator cuff repair, Mumford and subacromial decompression on 07/30/15.

DOI: 06/23/2004. Patient is a 51-year-old male driver who sustained injuries to his neck and back when he was rear-ended. Patient is diagnosed with lumbar disc disease and lumbar spondylolisthesis.