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. MRI of the right shoulder obtained on 12/29/15 showed limited portions of the study due to motion artifact.
DOI: 12/18/2014. The patient is a 56-year old male route sales representative who sustained a work-related injury to his lower back due to slip/fall on black ice while walking from his truck. As per OMNI entry, he was initially diagnosed with lumbosacral sprain.
The patient has completed physical therapy, time, rest, medications, chiropractic care, and acupuncture with no alleviation of the pain. Significant pathology on the MRI is noted with degenerative disk disease, neural foraminal stenosis and a nerve root impingement in the cervical spine. Treatment plan includes epidural at the bilateral C5-C6 level, continuation with home exercise program and medications and follow up in 2 weeks.
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.
3. Partial thickness articular surface tear of the remaining portion of the supraspinatus tendon and infraspinatus tendon and subscapularis tendinopathy. 4. Severe osteoarthritis of the glenohumeral and acromioclavicular joint.
DOI: 01/31/2006. Patient is a 39-year-old male plumber who sustained a work-related injury to his back and elbow when he slipped and fell while going down the stairs. Per OMNI, he is status post lumbar fusion at L5-S1 on 7/19/10. The patient was declared permanent and stationary as of 8/15/11 with future medical care including physician visits, medications, possible surgery, bone growth stimulator, lumbar brace, and vocational retraining. On 12/18/12, he underwent removal of hardware and inspection of fusion.
DOI: 12/13/2012. This is a case of a 63-year-old male security officer who sustained a work-related injury to the right knee when he missed a step and fell down the stairs. As per Omni, the patient had a right knee meniscus tear. The patient had right knee replacement on 11/19/14.
DOI: 08/29/2006. Patient is a 57-year-old male bookbinding operator/route salesman who sustained injury when he was startled by a cat while making a delivery and fell. Per OMNI, he was initially diagnosed with lumbar herniated disk. The patient is currently temporary totally disabled due to knee surgery in April 2013. Based on the progress report dated 03/21/16, the patient reports that his low back pain tweaked again, after making the bed.
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.
Pain is located in the low back and left leg, rated as 4/10. There is associated numbness to the left thigh and foot, and pins and needles sensation to the left foot. He continues with Percocet with 80% help with use. CURES was very consistent and appropriate.
Clinical Orthopaedics and Related Research®, 471(4),
This is a 42-year-old female with a 2/7/2015 date of injury. A specific mechanism of injury has not been described. DIAGNOSIS: low back pain; Lumbago with sciatica right side; Myalgia 12/01/15 follow-up visit identified lower back pain. Patient rates the pain as 7/10. The pain is characterized as burning.
DOI: 4/16/2012. Patient is a 29-year-old male technician who sustained injury when he was 25-feet up on a ladder when the ladder slid and he fell onto the pavement. He had an open reduction internal fixation (ORIF x 2) for a compound tibia fibula fracture and had hardware removal in 4/25/2013. MRI of the lumbar spine performed on 3/24/2016 revealed L5-S1 small right paracentral disc protrusion without significant spinal canal stenosis or neuroforaminal narrowing.
DOI: 6/25/2007. Patient is a 37-year-old female store manager who sustained injury when a tote slipped off shelf and struck her left side of the body. Per OMNI, she is status post ulnar nerve decompression on 03/11/08, left De Quervain’s release on 09/08/09, spinal cord stimulator implant on 08/03/11 and shoulder surgery on 01/19/15. Per the PT attendance report dated 05/07/15, the IW has attended a total of 30 sessions for the left shoulder from 02/05/15 through 05/01/15.
An MRI was performed of the lumbar spine. The examination found no significant extra