Left Wrist Case Summary

Current request is for 1 Right Shoulder Arthroscopy, Debridement, and Rotator Cuff Repair; 1 Preoperative Consultation; and 1 Polar Care Circulating Cold Pad with Pump (E0218) between 1/26/2016 and

Based on the progress report dated 03/21/16, the patient reports that his low back pain tweaked again, after making the bed. He went to the emergency room last week and was provided with Toradol injection. He was told it was sciatica on the right leg. Now, it is in the center of the back and sacroiliac area. Current pain level is 8/10 with pain medications. He also reports that the left side of the back and leg is aggravated by sitting between 1 to 1.5 hours.

EXAMINATION: He continues awake and alert. He converses easily and appropriately. He is in no acute distress. Blood pressure 120/78. Pulse 70 and regular. Weight 177 pounds. Height 5 '6". Cranial nerves continue intact, including the extraocular eye movements being intact without nystagmus. Visual fields are full in both eyes. He had no papilledema or atrophy of either optic disc. Pupils react from 4 down to 2 mm, bilaterally brisk and round to light and accommodation. He continues to have good strength with normal bulk and tone throughout his extremities. He had normal sensation to light touch, pinprick, and vibration sensation throughout both upper and

Based on progress report dated 05/23/14, the patient reports of continued dull aching pain and burning sensation into the cervical spine. She received 2 cc of lidocaine with no epinephrine in the bilateral trapezius, cervical rhomboid, and cervical paraspinal muscles on this visit.

Based on progress report dated 07/06/15, the patient presents with chronic right knee pain, described as dull and achy. Pain is worsened by sittlng,standing, and walking, and relieved by walking/exercise.

Per the progress report dated 5/18/16, the patient complained of low back and left leg pain. Percocet decreases pain by 80% and enables him to perform light gardening and household chores. No side effects with Percocet use. He is doing well with current medications and is compliant with no aberrant behavior. Upon lumbar examination, motion is associated with increase in pain. Left seated straight leg raise is slightly positive. There is decreased sensation of the left anterior thigh. He has forward leaning stiff gait with ability for heel and toe rise.

The plaintiff lives at 606 East 49th Street in Brooklyn with his mother, aunt and grandfather. He is currently employed by Sprint. At the time of the accident he was employed by Metro PCS, he had worked with them for 2 years prior to the accident as a customer service agent. He had health insurance but no fault paid his medical bills.

S: TM works in GA Chassis when he injured his right FA. According to TM he was putting in nuts on the exhaust muffler and a piece of metal was sticking out of the muffler and stuck him in his right FA. TM denies previous injury to right arm. TM rates his pain at 2/10.

Patient has had progressive pain, numbness, and weakness in both lower extremities. He has had an epidural, physical therapy, and medications. It was reiterated that the patient has lost over 30 pounds. He has clear-cut instability as documented by the pars fracture and the spondylolisthesis, which is mobile on flexion/extension films.

Patient 8: Col. Bradley J., Male age 56. He’s a Coronel in the military. With an annual income of $48,000. He also suffers from hypertension and is expected to live two years without the procedure.

DOI: 07/17/2013. This is a 25-year-old female cashier who incurred injury to her low back when she missed a step and fell off a ladder while stocking sleeping bags. MRI of the lumbar spine dated 10/03/2013 revealed broad based central disc protrusion at L4-L5; moderate discogenic edema along endplates at L4-5; and broad bulge with a central annual tear at L5-S1. CT scan of the lumbar spine dated 01/08/2014 revealed that at L3, bilateral pars interarticularis defects are seen with sclerotic margins. The vertebrae at L3-4 are normal in present on the prior MRI. The vertebrae at L3-4 are normal in alignment. At L4-3, there is 2 mm of anterolisthesis. Bilateral L4 pars interarticularis defects are seen with sclerotic margins. Office notes dated 06/28/2016

Per AME report by Dr. Sommer dated 05/28/14, the patient is P & S since 06/13/13.

He previously had facet joint injections but only with short term good benefit. He continues to take ibuprofen and Robaxin as needed.

PHYSICAL EXAM: The patient 's swelling is greatly reduced. Incision is well healed and shows no

Per medical report dated 06/16/2015 by Dr. Lemley, the patient complains of pain and dysfunction to bilateral hands/wrists. She has right greater than left discomfort in her thumbs with numbness.