DOI: 2/14/2014. The patient is a 54-year-old female janitor who sustained a work-related injury to her back and right arm from a slip and fall on snow and ice. As per OMNI, she was diagnosed with low back pain and radiculopathy. The patient underwent bilateral decompressive laminectomy on 8/12/15.
As per progress notes on 11/3/15 by Dr. Cristian Brotea, the patient is 3 months status post L4-S1 lumbar laminectomy and fusion with instrumentation from which she has been doing relatively well. She has experienced significant improvement in her mobility with physical therapy and she has been walking quite a bit. She is doing well during the day; however, she does have discomfort mostly at night in her lower back. She has been wearing a bone growth stimulator. She has not been able to take any pain medications/muscle relaxants.
Per medical report dated 12/14/15 by Dr. Liu, the IW presents for follow-up, complaining of low …show more content…
She is walking very slowly favoring her right lower extremity. Range of motion at the lumbar spine is minimal at best upon evaluation and removal of her Flector patch. Muscle spasms are noted throughout the lumbar paraspinous region with a small activity in the medium musculature. Light touch sensation to the lower extremities is decreased in the right L5 pattern. Tendon reflexes are decreased in the right ankle. No muscle atrophy is appreciated except for the spot in the low back Impression is lumbar disc derangement, status post lumbar fusion surgery with ongoing pain and muscle spasms and lower extremity radicular symptoms. IW was advised to stop Neurontin and cyclobenzaprine. She was given a prescription for Lorzone and Horizant to decrease her radicular symptoms with less side effects. She will continue on her tramadol. She will continue her physical therapy. She will return to the office in one month’s time.
Attached is the IME report dated 08/26/14 by Dr.
As per progress notes on 11/3/15 by Dr. Cristian Brotea, the patient is 3 months status post L4-S1 lumbar laminectomy and fusion with instrumentation from which she has been doing relatively well. She has experienced significant improvement in her mobility with physical therapy and she has been walking quite a bit. She is doing well during the day; however, she does have discomfort mostly at night in her lower back. She has been wearing a bone growth stimulator. She has not been able to take any pain medications/muscle relaxants.
Per medical report dated 12/14/15 by Dr. Liu, the IW presents for follow-up, complaining of low …show more content…
She is walking very slowly favoring her right lower extremity. Range of motion at the lumbar spine is minimal at best upon evaluation and removal of her Flector patch. Muscle spasms are noted throughout the lumbar paraspinous region with a small activity in the medium musculature. Light touch sensation to the lower extremities is decreased in the right L5 pattern. Tendon reflexes are decreased in the right ankle. No muscle atrophy is appreciated except for the spot in the low back Impression is lumbar disc derangement, status post lumbar fusion surgery with ongoing pain and muscle spasms and lower extremity radicular symptoms. IW was advised to stop Neurontin and cyclobenzaprine. She was given a prescription for Lorzone and Horizant to decrease her radicular symptoms with less side effects. She will continue on her tramadol. She will continue her physical therapy. She will return to the office in one month’s time.
Attached is the IME report dated 08/26/14 by Dr.