Work Related Injury: A Case Study
DOI: 9/4/2014. The patient is a 40-year old male carpenter who sustained a work-related injury to his low back and left shoulder after lifting a heavy beam at work. Patient is status post lumbar ESI at L5-S1 per procedure report dated 05/13/15.
Per the PT daily treatment note dated 0/09/14, the IW has attended 6 sessions for the back.
Per the AME done on 11/13/15 by Dr. Warbritton, Whole Person Impairment (WPI) rating for the back is 8%. Future medical care includes independent strengthening and stretching exercise program, medications, back brace, transcutaneous electrical nerve stimulation unit (TENS) and single diagnostic and therapeutic lumbar ESI for flare-up. Further diagnostic studies are not indicated. IW is not a candidate for any …show more content…
Range of motion allows for 10 degrees of flexion at the hips with forward reach to the midshin, extension of 2O degrees and lateral bending of 30 degrees bilaterally. Neurologic examination of the lower extremities reveals decreased sensation in the left calf and heel. Deep tendon reflexes are unobtainable in the lower extremities.
As of this report, X-rays of the lumbar spine with seven views obtained on this visit revealed five lumbar vertebrae, normal disc spaces, normal lumbar lordosis and alignment, no evidence of instability or stress fracture, no significant degenerative changes and no evidence of foraminal stenosis or narrowing.
An MRI of the lumbar spine dated 12/06/14 (no official report) was reviewed showing a herniated disc at L5-S1 on the left side as well as an annular tear and bulge at L3-4, L4-5 and L5-S1 levels.
Patient was diagnosed with low back pain and left sciatica with findings of S1 radiculopathy secondary to left L5-S1 disc herniation. MD noted that his lumbar MRI should be repeated since it is over a year old.
Current request is for 1 MRI of the Lumbar Spine without Contrast between 3/9/2016 and
Per the PT daily treatment note dated 0/09/14, the IW has attended 6 sessions for the back.
Per the AME done on 11/13/15 by Dr. Warbritton, Whole Person Impairment (WPI) rating for the back is 8%. Future medical care includes independent strengthening and stretching exercise program, medications, back brace, transcutaneous electrical nerve stimulation unit (TENS) and single diagnostic and therapeutic lumbar ESI for flare-up. Further diagnostic studies are not indicated. IW is not a candidate for any …show more content…
Range of motion allows for 10 degrees of flexion at the hips with forward reach to the midshin, extension of 2O degrees and lateral bending of 30 degrees bilaterally. Neurologic examination of the lower extremities reveals decreased sensation in the left calf and heel. Deep tendon reflexes are unobtainable in the lower extremities.
As of this report, X-rays of the lumbar spine with seven views obtained on this visit revealed five lumbar vertebrae, normal disc spaces, normal lumbar lordosis and alignment, no evidence of instability or stress fracture, no significant degenerative changes and no evidence of foraminal stenosis or narrowing.
An MRI of the lumbar spine dated 12/06/14 (no official report) was reviewed showing a herniated disc at L5-S1 on the left side as well as an annular tear and bulge at L3-4, L4-5 and L5-S1 levels.
Patient was diagnosed with low back pain and left sciatica with findings of S1 radiculopathy secondary to left L5-S1 disc herniation. MD noted that his lumbar MRI should be repeated since it is over a year old.
Current request is for 1 MRI of the Lumbar Spine without Contrast between 3/9/2016 and