CLINICAL SUMMARY: 286806
DOI: 06/07/2016. Patient is a 48-year-old male sales representative who sustained a work-related injury while walking downstairs to mechanical room when he slipped and fell.
CT of the cervical spine obtained on 06/12/16 showed degenerative changes, most pronounced at the-C6-C7 level.
Per the Neurology IME report dated 10/07/16, the IW has not reached maximum medical improvement. He has a moderate, 50% partial disability. He should be seen by his physician once a month for three months and then should be re-evaluated.
Per the PT note dated 11/08/16, the patient has been seen for 18 sessions. It was noted that the IW presented with pain and decreased range of motion, resulting to difficulty performing activities of daily living. MRI of the cervical spine dated 11/11/16 showed advanced disc degeneration between C5-7 with broad disc osteophyte complexes leading to significant spinal canal stenosis and neural foraminal stenosis, exacerbated by either a long segment of bony ridge or slender herniation between C5-7, further flattening the cord. There is a minimal C2-3 central herniation, which just flattens the …show more content…
He now has limitation over the last 1.5 weeks in range of motion of the neck to just 15 degrees laterally. There is also bilateral neck paraspinal tightness. In addition, headaches worsened at the same time as well. He has been going to physical therapy for the neck and lumbar spine after a concussion. Physical therapy has been helping to improve patient’s symptoms of concussion, lumbar back pain, and neck pain, but recently has had a worsening of his symptoms as PT ended. Furthermore, patient reports that pain is going up the neck, feels bad during the day; and pressure is from behind eyes and temple. He reports constant headache and rates at 3-4/10 during the day. Patient requires hydrocodone every night as necessary for the last couple of
DOI: 06/07/2016. Patient is a 48-year-old male sales representative who sustained a work-related injury while walking downstairs to mechanical room when he slipped and fell.
CT of the cervical spine obtained on 06/12/16 showed degenerative changes, most pronounced at the-C6-C7 level.
Per the Neurology IME report dated 10/07/16, the IW has not reached maximum medical improvement. He has a moderate, 50% partial disability. He should be seen by his physician once a month for three months and then should be re-evaluated.
Per the PT note dated 11/08/16, the patient has been seen for 18 sessions. It was noted that the IW presented with pain and decreased range of motion, resulting to difficulty performing activities of daily living. MRI of the cervical spine dated 11/11/16 showed advanced disc degeneration between C5-7 with broad disc osteophyte complexes leading to significant spinal canal stenosis and neural foraminal stenosis, exacerbated by either a long segment of bony ridge or slender herniation between C5-7, further flattening the cord. There is a minimal C2-3 central herniation, which just flattens the …show more content…
He now has limitation over the last 1.5 weeks in range of motion of the neck to just 15 degrees laterally. There is also bilateral neck paraspinal tightness. In addition, headaches worsened at the same time as well. He has been going to physical therapy for the neck and lumbar spine after a concussion. Physical therapy has been helping to improve patient’s symptoms of concussion, lumbar back pain, and neck pain, but recently has had a worsening of his symptoms as PT ended. Furthermore, patient reports that pain is going up the neck, feels bad during the day; and pressure is from behind eyes and temple. He reports constant headache and rates at 3-4/10 during the day. Patient requires hydrocodone every night as necessary for the last couple of