Patient Evacuation

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.

A visit note from Gregory Carico, MD (Internal Medicine), dated 01/23/2017, indicated that the claimant presented with a history of depression. She was involved in a motor vehicle accident on December 9th. She was relieved from work duties from 12/09 to 01/04 and was able to return to work on 01/10. She was again off work on 01/12 for therapy. She had pain in the thoracic part of the back and lower neck to middle back. She was diagnosed with a sprain of ligaments of the thoracic spine. An

1000 Pt denied pain at this time and rate 0 on a scale of 0 to 10. Pt thanks me a lot for pain medication I gave her. Instruct the pt to report her pain early before it get worse so I can give pain medication. Pt verbalized understanding of the teaching. No sign of distress or discomfort at this time. Will continue to monitor………L.Gotora

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: 12/3/2012. The patient is a 49-year-old male route sales representative who sustained a work-related injury to his lumbar spine and shoulders while lifting a bread rack out of his truck. Patient is status post bilateral L4-5 laminotomy, complete facetectomy and foraminotomy on 01/14/15.

On the statement of medical necessity on the MG2 form dated 06/08/16, PT is requested at a rate of twice per week for 6 weeks for her left knee and secondarily, the left hip pain that is related directly to her altered gait.

Per PT treatment log dated 11/18/15, the patient has attended 19 PT visits for the thoracic and lumbar spine from 08/27/15 through 11/13/15.

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.

Per the Agreed Medical Re-Examination report dated 09/29/15, whole person impairment rating is 5%. Future medical care includes access to follow-up visits for monitoring of his condition for the next calendar year, with continued provision of pharmacological agents. Should patient experience a significant acute symptoms flare-up within the next calendar year, re-instatement of brief courses of traditional PT, acupuncture,

DOI: 06/23/2011. This is a case of 41-year-old male maintenance worker who sustained injury to the low back while taking off a sliding door of a patio. As per OMNI notes, patient is diagnosed with lumbar disc disorder with myelopathy. MRI of the lumbar spine dated 6/28/15 revealed recurrent left paramedian L4-5 disc herniation with caudal extrusion of a 10 mm fragment into the left L5 lateral recess. As per office notes dated 7/25/16, the patient is status post redo left L5-S1 discectomy performed on 4/20/16. It was also noted that the patient had a prior L5 laminotomy several years ago. He subsequently did well. However, he had recurrence of his pain. Pain is radiating into his left leg worse on the right leg. This was unresponsive to conservative

DOI: 9/30/1997. The patient is a 50-year-old female reservation clerk who sustained a work-related injury to her back and bilateral lower extremities when she tripped and fell.

The patient will continue physical therapy 1 day per week for 8 weeks where he will receive moist heat, cold packs, electrical stimulation, massage therapy, ultrasound to the right shoulder by followed by gentle range of motion and strengthening exercises with the goals of reducing pain, improving strength, improving range of motion, improving overall function, and teaching home exercise program.

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

Based on the progress report dated 05/17/16, the patient presents for reevaluation of her right knee pain. It has been about the same though she states that when she gets acupuncture, it does decrease pain for a period of time and allow her to exercise more. She has been walking 45 to 50 minutes twice a day. She uses

Based on the medical report dated 11/11/15, the patient returns for post-operative visit. He feels better and is doing well. He still has a bit of soreness and stiffness, which is expected at this time. He has not started any formal