Review # 258421 william Rose DOI: 4/24/1991. DOI: 4/24/1991. The patient is a 72-year old male truck driver who sustained injury to his back as a result of driving the truck over a rut on the road. The patient was subsequently diagnosed with lumbar spondylosis, lumbar degenerative disc disease, other specified postprocedural states, and lumbago.
DOI: 11/16/2015. Patient is a 57-year-old right hand dominant male mechanic who sustained injury while he was lifting a metal roller when he lost his balance and fell backwards. Per OMNI, he was initially diagnosed with head laceration which required 7 sutures and right shoulder full thickness supraspinatus tendon tear, confirmed by 12/29/15 MRI.
DOI: 2/6/2003. The patient is a 46-year old female aide who sustained a work-related injury to her low back while she was transferring a high school student from wheel chair to table. MRI of the lumbar spine dated 2/19/16 revealed T12-L1, there is no focal posterolateral right disc protrusion; L1-2, no posterior disc protrusion/osteophyte complex; L2-3 , no posterior disc protrusion/osteophyte complex; L3-4, there is lateral left disc protrusion/osteophyte complex; L4-5, there is an approximately 3 mm posterior disc protrusion/osteophyte complex; and L5-S1, there is mild posterior disc/osteophyte complex.
DOI: 01/05/2004. Patient is a 64-year-old female nurse who sustained a work related injury to her cervical spine, lumbar spine, and bilateral shoulders during the course of performing her normal job duties. She is statius post bilateral L4-5 and L5-S1 facet blocks with fluoroscopy on 10/23/12. MRI of the lumbar spine dated 01/08/16 revealed moderate levoscoliosis; L1-L3 2-3mm posterior disc protrusion; L3-L4 4-5mm pseudo and/or true posterior disc protrusion; L4-L5 3-4mm posterior disc protrusion/extrusion; L5-S1 2-3mm posterior disc protrusion.
He has ongoing progressive back pain with numbness, pain and weakness in the left leg/foot and occasionally on the thigh. He has done physical therapy, but he would now like a definitive plan. Recommendation was made for a L4-5 decompression and fusion. He will need complete facet resection in order to alleviate that lateral recess stenosis, as well as a likely decompressive laminectomy at L3-4 and L5-S1. In the meantime, he was advised to continue physical therapy and home exercises.
He has an antalgic gait in lumbar flexion. Mr. Danes has reduced active range of motion of the lumbar spine, especially in 5 degrees of extension which reproduces his leg pain. The following orthopedic tests were positive: Minor 's’ sign, Kemp 's on the right, Yeoman 's’ bilateral, and Milgram
This pain stopped him from daily living activities such as driving, and also walking. A gait analysis was performed to find that he had an early heel rise on the left, and a short step length on the right. He had to have assistants from the rails to descend and ascend the stairs. Radiographs were performed and showed presence of retrocalcaneal exostoses.
Per pulmonary function tests, his condition was stable. Degenerative disc disease lower back and neck, lower back pain. Degenerative joint disease right knee. Right and left knee scope in 2008, right knee scope in 07/2010, decreased range of motion bilateral knees. Independent with activities of daily living.
DOI: 11/01/2001. This is a 64-year-old male operator who incurred injuries to his bilateral knees due to kneeling on the job. Patient is diagnosed with status post left total knee arthroplasty and symptomatic right knee arthrosis. As per office visit note dated 3/29/16, the patient states that the injection to his right knee was good for a few weeks.
Her PCP order radiographs and an MRI both which appeared unremarkable.2 Due to the negative radiographs, her PCP referred her to an orthopedic who linked her back pain to lifting boxes at work, prescribed analgesics, and referred the patient to physical
He said he was feeling a sharp pain in his right lower back. He also, explained that he had the pain in his left lower back at first but then the pain traveled to his right side. He did not take any Ibuprofen for the pain at all, and he only felt the pain when trying to fully bend over, for example; to pick something from the floor, or touch his toes.