Voluntary Observation Report

Pain is rated at 3-4/10. The patient saw Dr. Abbassi on 05/07/15 who recommended diagnostic medial branch blocks around L4-L5 and L5-S1 on the right side, 2 levels. The patient would like the medial branch blocks to be done. Dr. Abbassi further writes, “I believe he is a candidate for diagnostic medial branch blocks, 2 levels, at the time starting from L4-L5 and L5-S1 on the right, later L2- L3 and L3-L4 if he still has pain, and if these injections help him for a short while but significantly and then the pain returns then radiofrequency ablation is an option.” Diagnoses are chronic fracture of T8, upper thoracic pain, lumbar pain with radiation to left L5 region with left L5 radicular pain with moderate listhesis at L4-5 and mild to moderate bilateral L5-S1 denervation. Treatment plan includes diagnostic medial branch blocks, 2 levels, right sided, at L4-L5 and L5-S1, to await approval for physical therapy, modified duty, and follow-up in 4 weeks.

Diagnosis: Other spondylosis with radiculopathy lumbar region, other spondylosis with radiculopathy lumbosacral region, Sacroiliitis, Sacrococcygeal disorders, Low back pain, other intervertebral disc displacement, lumbar region

Based on the latest medical report dated 04/08/16, the patient presents for follow-up of his lower back pain. He is status post radiofrequency facet on the left that initially helped with left sided lower back to 60%. He stated that PT was stopped by insurance for the past 2 weeks. Since he started PT, he has been having increased spasm across his lower back with pain into the left lower extremity. IW feels that PT

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.

In addition, CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. As noted above, this is an appeal to the previously denied request on 02/09/16. The appeal letter states that the patient has low back pain. MRI report showed disc bulge at L5-S1 with left neural foramina narrowing. However, 01/06/16 progress report noted that there was no radiculopathy with a negative SLR on exam. The guidelines require documentation of radiculopathy on exam. In addition, there is no documentation of a trial or failure of conservative treatment, including PT, as recommended by the guidelines. Furthermore, there is no documentation of any focal neurological deficits on the exam that would indicate nerve pathology. The motor and sensory exam was normal. Medical necessity has not been established. Recommend

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.

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,

Patient has been previously denied 1 Transforaminal Lumbar Interbody Fusion at L4-L5 Level on 09/09/15 (Review

Assessments include lumbosacral intervertebral disc disorders with radiculopathy, lumbar spondylosis without myelopathy or radiculopathy and myalgia.

Moses was born in Leitrim, Ireland and lived there until he was six years old. His family moved to Greenville, SC where he grew up. As a child, Moses wanted to be a forest ranger or a pilot. Even though he hasn’t lived outside of South Carolina, every once in a while he travels to North Carolina, Florida and Georgia. He went to a small private high school called Hampton Park, where he also played soccer for three years. His high school didn’t have a lot to offer in regards to groups or clubs, but he did dance quite a bit. He has tried blues and lindy, but swing and contra dancing are still his favorites. His other interests and hobbies include biking at Clemson, rock wall climbing, hiking and climbing buildings. When it comes to sports, he enjoys watching soccer and his favorite teams are FC Bayern Munich and Clemson.

Treatment plan includes follow up evaluation in 6 weeks, follow-up visits and right ESI at L4-5 level as the patient has persistent subjective complaints suggestive of radiculopathy. The epidural injection is required because of spinal surgery recommendations.

After analyzing findings from the initial evaluation the patient’s primary issue is severe right hip/knee pain which is limiting his ability to participate in PT, as well as perform functional activities. Therefore, identifying the source of pain is the main priority since the patient’s pain is 5/10 at rest and 7/10 with bed mobility, transfers, and ambulation. Taking into consideration the high pain levels and unknown source; the patient was discharged and recommended to follow up with his MD. This being said, below are potential concerns involving the combination of medications and impairments during interventions if this patient remained in Neuro Clinic with minimal pain.

As per medical report dated 3/10/2016, patient complains of low back pain rated at 7/10 with left lower

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.

While at the Volunteer fair I found out about different organizations that anyone can help with in order to benefit other people. I was able to talk to someone from Alternatives Incorporated where they help give individuals support and help people with disabilities. Before going to this event, I was unaware that such organizations existed and that you could be given a chance to volunteer your time to them. At the volunteer fair you are able to learn about foundations and organizations that you never knew of. I enjoyed the event, I think it is a good way for first year students to contribute to their community. The volunteer fair makes students think about other people and put effort in to doing something other than school work. I would attend