Roustabout Case Study
DOI: 2/18/1987. Patient is a 55-year-old male roustabout who sustained injury while he was lifting an oxygen cylinder when he felt a pull in his low back. Per OMNI, he is status post percutaneous diskectomy at L4-5 and L5-S1 on 02/05/90.
Per pain management reports, the IW underwent a bilateral L4-5 and L5-S1 facet blocks on 06/12/07, 10/29/07 and 03/04/08.
Per medical report dated 12/29/08 by Dr. West, IW presented with continuation of his lumbar symptoms. Recent facet blocks have provided relief when he is home from Kuwait. MD opined that he would benefit from an additional facet block. Lortab was refilled.
MRI of the lumbar spine obtained on 12/29/08 revealed bilateral spondylolysis and grade 2 spondylolisthesis at L4-5 in …show more content…
Based on the medical report dated 01/27/16 by Dr. West, the patient has a Grade 2 L4-5 listhesis. He complains of increased pain in his low back and both lower extremities, worse on the left with radicular component in the left. He has a history of neurogenic claudication. As of this report, X-rays obtained on this visit confirmed an L4-5 degenerative spondylosis.
Per medical report dated 02/19/16 by Dr. West, the patient is status post a work related 7 to 8 years ago. He states that he has had consistent and constant pain in his low back, buttock and posterior thigh since that time. He has been in Afghanistan working light duty which he tolerated reasonably well, but now that he has returned home with increased activity, he has had significant increase in his pain. He has had no recurrent injury. MD opined that this is a preexisting Grade 2 spondylolisthesis, exacerbated by his work related injury. On physical examination, he has lumbar spasm, tenderness, pain on forward flexion and positive straight leg raise. Plan is to proceed with an MRI of the lumbar spine.
Per the adjuster, the doctor’s first report of occupational injury is not
Per pain management reports, the IW underwent a bilateral L4-5 and L5-S1 facet blocks on 06/12/07, 10/29/07 and 03/04/08.
Per medical report dated 12/29/08 by Dr. West, IW presented with continuation of his lumbar symptoms. Recent facet blocks have provided relief when he is home from Kuwait. MD opined that he would benefit from an additional facet block. Lortab was refilled.
MRI of the lumbar spine obtained on 12/29/08 revealed bilateral spondylolysis and grade 2 spondylolisthesis at L4-5 in …show more content…
Based on the medical report dated 01/27/16 by Dr. West, the patient has a Grade 2 L4-5 listhesis. He complains of increased pain in his low back and both lower extremities, worse on the left with radicular component in the left. He has a history of neurogenic claudication. As of this report, X-rays obtained on this visit confirmed an L4-5 degenerative spondylosis.
Per medical report dated 02/19/16 by Dr. West, the patient is status post a work related 7 to 8 years ago. He states that he has had consistent and constant pain in his low back, buttock and posterior thigh since that time. He has been in Afghanistan working light duty which he tolerated reasonably well, but now that he has returned home with increased activity, he has had significant increase in his pain. He has had no recurrent injury. MD opined that this is a preexisting Grade 2 spondylolisthesis, exacerbated by his work related injury. On physical examination, he has lumbar spasm, tenderness, pain on forward flexion and positive straight leg raise. Plan is to proceed with an MRI of the lumbar spine.
Per the adjuster, the doctor’s first report of occupational injury is not