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Alicia XXXX DOB: 01/27/YYYY

MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW

General Instructions:

Brief Summary/Flow of Events: In the beginning of the chronology, a Brief Summary/Flow of Events outlining the significant medical events is provided which will give a general picture of the focus points in the case

Patient History: Details related to the patient’s past history (medical, surgical, social and family history) present in the medical records

Detailed Medical Chronology: Information captured “as it is” in the medical records without alteration of the meaning. Type of information capture (all details/zoom-out model and relevant details/zoom-in model) is as per the demands of the case which will be elaborated under the ‘Specific Instructions’

Reviewer’s Comments:Comments on contradicting information and misinterpretations in the medical records, illegible handwritten notes, missing records, clarifications needed etc. are given in italics and red font color and will appear as * Reviewer’s Comment

Illegible Dates: Illegible and missing dates are presented as “00/00/0000”(mm/dd/yyyy format)

Illegible Notes: Illegible handwritten notes are left as a blank space “_____” with a note as “Illegible Notes” in the heading of the particular consultation/report.

Specific Instructions:1. Chronology focuses on MVA on 03/17/YYYY, the injuries sustained and the subsequent treatments 2. The missing records are indicated in the chronology3. The case specific key points are highlighted for easy reference

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Injury Report

PARAMETER DETAILS PDF REF

Injuries and Significant

Medical Condition Before

Accident

Past medical history: Negative

Past surgical history: Negative

15

Injuries directly as a result of

accident?

Lumbar spine strain/ sprain leading to multiple lumbar spine disc

herniations

Lumbar spine radiculopathy with herniated nucleus pulposus

Right shoulder strain/ sprain leading to shoulder tendinopathy

Left ankle non- displaced avulsion fracture of the lateral malleolus with

partial tears of the anterior talofibular and calcaneofibular ligaments

Left foot pain

Right wrist/hand strain/ sprain

Anxiety and depression

193-196, 4, 185-

187, 18-19, 90-

92

Did any prior injury/medical

condition aggravate after the

accident?

No

Did any new injuries/medical

condition (not related to the

accident) develop?

No

Did patient return to work? No, on 06/27/YYYY, it was stated that the patient remained unable to work

at that time

90-92

Impact of Injury on

ADLs/Quality of Life?

Since the collision, she had difficulty lifting, carrying, bending, sitting and

prolonged standing.

45-46

Disability (if any) Not applicable

Medical Condition of Patient

as per last available records

(any treatment/surgery that

they will need)

08/02/YYYY- This patient complains of persistent low back pain into lower

extremities- Patient is to home physical therapy, refraining from any

activity that exacerbates symptoms such as lifting, carrying, bending,

twisting, and has been advised to follow- up in several weeks for a repeat

evaluation.

45-46

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Patient History

Family History: Significant for arthritis in father

Social History: She is self- employed as a cleaner. She doesn’t smoke and drink

Allergy: No Known drug allergies

Detailed Chronology

DATE PROVIDER OCCURRENCE/TREATMENT PDF REF03/17/YYYY

ABCD Hospital

1927 hrs- ER visit (Illegible notes)Priority code: 4Mode of arrival: Ambulance*Reviewer’s comment: Ambulance report is unavailable for review.

Chief complaints: Patient complains of left knee, left ankle and low back pain. From slow speed pedestrian struck. Pain scale: 7-9

Physical examination: Back tender- Paravertebral tenderness. Left knee and ankle tenderness.

Gait: Painful gait

Impression: Multiple contusion

Treatment: Ibuprofen 600 mg

Plan: Cold compress first 24 hours and then warm compress. Rest 48 hours. Follow-up Elmont Health Center.

30-35

03/26/YYYY

ABCD Physical Medicine & Rehabilitation, P.C.

Raj XXXX, M.D.

Initial Physiatric evaluation:Chief complaint: The patient presents to the office today for initial evaluation with chief complaints of right shoulder pain, right wrist/hand weakness, low back pain, and left foot/ankle pain.

History of Present Illness (HPI): The patient is a 38 year old, right-handed female who was injured in a pedestrian versus motor vehicle accident on March 17, YYYY. The patient was crossing the street when she was hit on her right side by a car. She fell to the ground, but denies any head trauma or loss of consciousness. She was brought by ambulance to ABCD Hospital. She was given Ibuprofen for pain control. She was sent home on the same day and was advised to follow-up. She is currently complaining of right shoulder pain, which is especially prevalent with range of motion. She also notes right wrist/hand weakness, which is especially prevalent with gripping objects. She also notes low back pain, which radiates to the right lower extremity and she complains of numbness and tingling of the right leg. She also notes left foot/ankle pain, which is constant in nature but increases with ambulation. She presents today for further evaluation.

193-196

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REF

Activities of daily living: Because of her pains, she notes difficulty bending, lifting, and carrying things. She has difficulty ambulating. She has difficulty performing her household chores.

Physical examination: Musculoskeletal exam:Lumbar spine: Range of motion flexion 50 degrees (normal 90 degrees), extension 20 degrees (normal 30 degrees). There is tenderness to palpation over the lumbar paraspinal musculature. Right shoulder: Active abduction and flexion is limited to 80 degrees. Passive abduction and flexion is limited to 100 degrees secondary to pain.Right wrist/hand: There is no swelling noted, but there is tenderness to palpation over the dorsal and volar aspects of the wrist. Grip strength is 4/5. Left foot/ankle: There is swelling with tenderness to palpation in the area of the lateral malleolus. Dorsiflexion is limited to neutral.

Assessment: Status post pedestrian versus motor vehicle accident on March 17, YYYY Lumbar spine strain/ sprain Right shoulder strain/ sprain Left foot/ankle strain/ sprain Right wrist/hand strain/ sprain

Recommendations: The patient will begin physical therapy five days per week for two weeks, where she will receive moist heat, cold packs, electrical stimulation, ultrasound, and massage therapy to the lumbar paraspinals, right shoulder, right wrist/hand, and left foot/ankle, paraffin treatments to the right hand/wrist, range of motion and strengthening exercises, with the goals of reducing pain, improving range of motion, and improving overall function.

I am advising that she see an orthopedic surgeon for further evaluation and management of her right shoulder, left foot/ankle, and right wrist/hand complaints.

I have given her a prescription for enteric-coated Naprosyn 500 mg to be taken twice daily for an anti- inflammatory and pain-relieving effect. She can discontinue the use of Ibuprofen, but may continue to take Tylenol as needed for her pain as long as that is okay with her regular medical doctor.

I will re-evaluate this patient in 2 weeks or sooner if needed.

Causality: If the above history is correct, then there is a causal relationship between the patient’s pedestrian versus motor vehicle accident on March 17, YYYY and her above complaints.

Disability: The patient is unable to work at this time. I have advised her to be careful and mindful of her injuries and not do any activities that would further exacerbate them.

04/07/ ABCD Follow-up for back and left foot pain: 189-191

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFYYYY Physical

Medicine & Rehabilitation, P.C.

Raj XXXX, M.D.

Chief complaints: The patient notes episodic right shoulder pain, which has improved since our initial evaluation. She notes intermittent right wrist/hand pain, which is also improved since our initial evaluation. She continues to note episodic low back pain, which radiates to the right lower extremity. She continues to note left foot/ankle pain, which is especially prevalent with ambulation.

Physical therapy: The patient has attended a total of nine sessions of physical therapy thus far and she participates in a daily home exercise program.

Assessment: Status post pedestrian versus motor vehicle accident on March 17, YYYY Lumbar spine strain/ sprain. Rule out lumbar spine disc herniation Left ankle strain/ sprain. Rule out internal derangement Right shoulder strain/ sprain. Rule out rotator cuff pathology Right wrist strain/ sprain

Recommendations: The patient will continue physical therapy, but frequency will be decreased to three days per week. She will receive moist heat, cold packs, electrical stimulation, ultrasound, and massage therapy to the lumbar paraspinals, right shoulder, right wrist/hand, and left ankle, paraffin treatments to the right wrist/hand, range of motion and strengthening exercises, Theraband exercises for the left foot/ankle, with the goals of reducing pain, improving range of motion, and improving overall function.

I am advising that she undergo an MRI of the lumbar spine to rule out any disc herniations causing her pain and limited range of motion. I am also advising that she undergo an MRI of the left ankle to rule out any internal derangement causing her pain, swelling, tenderness, and limited range of motion.I am also advising that she undergo an MRI of the right shoulder to rule out any rotator cuff pathology causing her pain and limited range of motion.She was advised to see Dr. XXXX, orthopedic surgeon, as scheduled for further evaluation and management of her right shoulder, left foot/ankle, and right wrist/hand pains. She can continue taking Tylenol as needed for her pain as long as that is okay with her regular medical doctor.

I will re-evaluate this patient in 4 weeks time.

Disability: The patient remains unable to work at this time.04/07/YYYY

Barry XXXX, M.D.

Office visit for left ankle and back pain:HPI: The back and the left ankle seem to be her pressing problems. She has had no prior problems with the ankle.

Work history: The patient works as a housekeeper and has not gone back to work.

Left ankle and foot: There is pain with inversion of the ankle. There is tenderness over the lateral collateral ligaments as well as the peroneal tendons.

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFImpression/ plan: I am sending her for an MRI to rule out a peroneus brevis or longus rupture. I have recommended getting an Aircast and doing alphabet exercises as well. I will see her back in my office next week to go over the MRI.

04/09/YYYY

QWERT

Richard XXXXXX, M.D.

MRI lumbosacral spine:History: MVA. Pain

Impression: Posterior disc herniations at L4-5 and at L5-S1 impinging on the anterior aspect of the spinal canal and abutting the nerve roots bilaterally. Mild to moderate spinal stenosis at L4-5 and at L5-S1.

2

04/09/YYYY

QWERT


MRI right shoulder:History: MVA. Pain

Impression: Increased signal in the supraspinatus tendon consistent with tendinopathy.

3

04/09/YYYY

QWERT


X-rays:History: MVA. Pain

Left ankle: Impression: Non-displaced avulsion fracture of the lateral malleolus.

Lumbosacral spine: Impression: Increased lordotic curvature. Minimal osteoarthritic change at L3-4.

Right shoulder: Impression: Normal examination.

4

04/13/YYYY

QWERT


MRI left ankle:Impression: Findings consistent with partial tears of the anterior talofibular and calcaneofibular ligaments.

1

04/14/YYYY

Barry XXXX, M.D.

Follow-up for left ankle pain:HPI: She notes some tenderness around the fibula but not necessarily at the tip. There is some pain with dorsiflexion and plantar flexion of the ankle. I have gone over the results with her

Impression/plan: I am going to see her back next week after she gets the MRI results.

14

04/14/YYYY


Raj XXXX, M.D.

Interim note regarding left ankle X-ray findings:I will stop physical therapy for the left ankle at this time. I have given the patient a copy of this X-ray and she was advised to continue following up with Dr. XXXX, orthopedic surgeon, for further evaluation and management.

I will re-evaluate this patient as scheduled.

192

04/19/YYYY

Barry XXXX, M.D.

Follow-up visit for left ankle and foot pain:HPI: She continues to have pain in the foot and ankle.

Physical examination: Left ankle and foot: There is good but not full range of motion. There is tenderness with valgus stress and some tenderness over the

8

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFlateral collateral ligament.

Impression/ plan: She should continue with therapy. I will see her back in my office in about a month’s time.

05/05/YYYY


Raj XXXX, M.D.

Follow-up visit for low back and right shoulder pain:Chief complaints: The patient notes episodic right shoulder pain with lifting and carrying objects in the right arm. She notes intermittent right wrist/hand pain, which continues to improve. She has episodic low back pain which intermittently radiates to the right lower extremity. She continues to note left foot/ankle pain, which is prevalent with ambulation.

Vocational history: The patient returned to work one week ago.Physical examination: Musculoskeletal exam:Lumbar spine: Range of motion flexion 75 degrees (normal 90 degrees), extension 25 degrees (normal 30 degrees).Right shoulder: Active abduction and flexion is limited to 130 degrees. Passive range of motion is full with pain at end range.Left foot/ankle: There is tenderness to palpation behind the lateral malleolus. Dorsiflexion is limited to 10 degrees past neutral (normal 20 degrees).

Assessment: Multiple lumbar spine disc herniations. Rule out lumbar radiculopathy Left ankle partial tears of the anterior talofibular and calcaneofibular

ligaments and a non-displaced avulsion fracture of the lateral malleolus Right shoulder supraspinatus tendinopathy Right wrist strain/sprain.

Recommendations: The patient will continue physical therapy three days per week. Therapy for the left foot/ankle will be deferred until I receive written clearance from an orthopedic surgeon. She was advised to continue following up with Dr. XXXX, orthopedic surgeon, for management of her right shoulder, right wrist/hand, and left foot/ankle pains.

I am advising that she undergo electro-diagnostic studies of the lower extremities to evaluate and differentiate between a possible lumbar radiculopathy versus a peripheral or entrapment neuropathy causing her pain, radicular symptomatology, and radicular findings on examination. I feel that the results of these studies can help us tailor her treatment and help us determine whether it would be appropriate to refer her for more invasive therapy such as the possibility of epidural steroid injections or perhaps even surgery.

She can continue taking enteric-coated Naprosyn 500 mg twice daily for an anti-inflammatory and pain-relieving effect.


185-187

05/27/YYYY

ABCD Physical Medicine & Rehabilitation,

Electromyography (EMG) /Nerve Conduction Study (NCV):Lower extremities and lumbar: Impression: The electrodiagnostic study reveals no evidence of lumbosacral radiculopathy, peripheral or entrapment neuropathy at this time.

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFP.C.

Raj XXXX, M.D.

05/27/YYYY


Raj XXXX, M.D.

Interim note regarding EMG/ NCV study results:Based in the results of this study, myofascial release to the lumbosacral paraspinals will be added to her physical therapy program.

I will re-evaluate this patient as scheduled.

254

06/14/YYYY


Raj XXXX, M.D.

Follow-up for low back and right shoulder pain:Chief complaints: The patient has episodic low back pain. She continues to note intermittent right shoulder pain and right wrist pain, which is prevalent with activity. She has left foot/ankle pain, which is prevalent with prolonged standing and ambulation. She continues to note improvement in her pains with physical therapy.

Vocational history: The patient continues to work on a part-time basis.

Physical examination: Musculoskeletal exam:Left foot/ankle: There is swelling with tenderness to palpation behind the lateral malleolus.

Recommendations: The patient will continue physical therapy three days per week. Therapy for the left foot/ankle will now be instituted as it has been nearly three months since her injury and I feel it is safe to begin therapy for the left foot/ankle. She was advised to continue following up with Dr. XXXX, orthopedic surgeon, for management her right shoulder, right wrist/hand, and left foot/ankle pains. She can continue taking Tylenol as needed for her pain.


Disability: The patient may continue to work as tolerated.

251-253

07/02/YYYY

Barry XXXX, M.D.

Follow-up visit for recovering left ankle pain:HPI: The patient is seen in follow up. She notes that her ankle is feeling much better. She has good range of motion and no tenderness to palpation.

Impression/ plan: At this point she should continue with therapy. I will see her back in my office as needed.

9

08/11/YYYY


Raj XXXX, M.D.

Follow-up visit for low back and left ankle pain:Chief complaints: The patient has episodic low back pain. She notes intermittent left foot/ankle pain when she is running.

Vocational history: The patient continues to work on a part- time basis.

Assessment: Right shoulder supraspinatus tendinopathy with clinically improved shoulder

248-250

8 of 17


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFpain

Right wrist strain/ sprain with clinically improved pain

Recommendations: The patient will continue physical therapy 3 days per week. Therapy for the right shoulder and right wrist/hand will be discontinued as the patient is no longer complaining of pain, and there are no focal deficits on examination. She is advised to continue following up with Dr. XXXX, for management of her left foot/ankle pain.

I will re- evaluate this patient in 6 weeks time.

Disability: The patient may continue to work as tolerated.05/10/YYYY- 09/27/YYYY


Raj XXXX, M.D.

Summary of multiple Physiatric follow-up visits for her low back pain, left ankle pain, right shoulder and right wrist pain:Treatment areas: Low back, right shoulder, right wrist and hand and left ankle foot.Treatment given: Therapeutic exercises, electrical stimulation, hot/ cold packs and massage.

Prognosis: As of from May 10, YYYY to September 27, YYYY, she was under regular Physiatric follow-up visits for her persistent low back pain, left ankle pain, right shoulder pain and right wrist and hand pain. Following rehabilitation she had good prognosis pertaining to her right shoulder and right wrist pain, but she continued to have low back and left ankle pain. On September 27, YYYY, she complained of deep aching pain and stiffness in her low back, left ankle and foot. She was managed with therapeutic exercises and was advised to continue with the therapy.

*Reviewer’s comment: Multiple Physiatric follow-up visits have been combined with a brief summary of patient prognosis.

299-305, 292-298285-291269-284267-26893-103

09/29/YYYY


Raj XXXX, M.D.

Follow-up visit for pain complaints:Chief complaints: The patient is no longer complaining of low back pain and she denies any lower extremity pain, paresthesias, or weakness. She is no longer complaining of left foot/ankle pain.

Vocational history: The patient continues to work on a part-time basis.

Recommendations: At this point in time, I feel that the patient has plateaued and has reached maximal medical benefit from formal physical therapy and as such, I will discontinue it. The patient was advised that she may continue to suffer from periodic exacerbations in her pain and limitations in her abilities. She was advised that when she has an exacerbation in her pain that she should continue with her home exercises and take over-the-counter medications on an as-needed basis. She was also advised that if, at any time, these measures do not adequately control her exacerbations that she could contact us for the possibility of a re-evaluation and the possibility of a re-institution of a formal physical therapy program.

She will be re-evaluated on an as-needed basis.

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Disability: The patient may continue to work as tolerated.12/16/YYYY


Raj XXXX, M.D.

Dr. Raj XXXX’s opinion on Dr. Mitchell XXXXXX peer review: I respectfully disagree with the peer review performed by Dr. Mitchell XXXXXX, on June 25, YYYY. He states that medical necessity of the EMG/NCV/H of the lower extremities has not been met in this case.

Dr. XXXXXX states that this case there was no evidence of peripheral neuropathy or entrapment. He states this was an instance of soft tissue trauma to the lumbar spine and there were no clinical findings of lumbar radiculopathy. This is a completely false statement. In my examination dated May 5, YYYY, the patient complains of low back pain with intermittent radiation to the right lower extremity. This pattern of pain can be due to a radiculopathy, peripheral neuropathy, or entrapment neuropathy. Therefore it is clear that this is not an instance of soft tissue trauma to the lumbar spine, but that there is significant disc pathology of the lumbosacral spine.

72-74

Medical records from 12/16/YYYY to 04/06/YYYY are missing for review04/06/YYYY

Sebastian YYYY, M.D.

Office visit for low back pain:Chief complaint: Patient is complaining of low back pain and lower extremity radiation.

HPI: Patient involved in a motor vehicle accident sustaining injury to the low back as a result of it. Patient has been symptomatic since the accident and was asymptomatic prior. Patient has had conservative treatment, however, remains severely symptomatic.

Patient presents today complaining of low back pain, lower extremity radiation with numbness, tingling and dysesthesias. Patient describes pain as being daily, constant and persistent with a pain severity score of 8 out of 10. Patient’s symptoms are made worse and interfere with daily activities such as lifting, carrying, bending, standing /sitting for prolonged periods of time, ascending/descending stairs.

*Reviewer’s comment: The patient was involved in an MVA on 03/17/YYYY but in this visit it is mentioned as 05/27/YYYY which is contradicting.

Musculoskeletal physical examination: Spine examination:Inspection to percussion and palpation shows tenderness and spasms noted. There are restricted ranges of motion, 20 degrees of flexion (90° is normal), 10 degrees of extension (40° is normal), left and right turning to 15 degrees (60° is normal).

Neurological: Sensation is decreased in the L4, L5 and S1 bilateral nerve root distributions.

Diagnosis: Lumbar spine radiculopathy and Herniated Nucleus Pulposus (HNP).

Plan: An overview of different treatment options were discussed with this patient including surgical and non-surgical modalities for amelioration of

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFsymptoms, such as chiropractic care/ physical therapy, epidural steroid injections and medication. Patient has elected to proceed with conservative treatment to include physical therapy.

The patient is considering the discussed treatment plan of lumbar spine epidurals. Patient is to refrain from any activity that exacerbates symptoms such as heavy lifting, carrying or bending and follow up in several weeks for a repeat evaluation.

04/27/YYYY

XYZA Spine Specialist, LLP

Giovanni XXXXX, M.D.

Lumbar epidural steroid injection report:Indication: Failure of conservative management and chronic pain represents the indication for an epidural steroid injection.

Diagnosis: Lumbar sprain, radiculopathy, HNPProcedure: Lumbar epidural steroid injection- 1st

Plan: Patient was given a follow-up appointment in one week for an additional injection in the event that patient has not reached maximum medical improvement from today’s injection.

20

05/25/YYYY



Lumbar epidural steroid injection report:Procedure: Lumbar epidural steroid injection- 2nd

Plan: Patient was given a follow-up appointment in one week for an additional injection in the event that patient has not reached maximum medical improvement from today’s injection.

21

06/05/YYYY



Lumbar epidural steroid injection report:Procedure: Lumbar epidural steroid injection- 3rd

Plan: Patient was given a follow- up appointment in two weeks for another evaluation.

22

07/14/YYYY


Follow-up visit for low back pain:Chief complaint: Patient is complaining of low back pain and lower extremity radiation.

HPI: Patient presents today complaining of low back pain, lower extremity radiation with numbness, tingling and dysesthesias. Patient describes pain as being daily, constant and persistent with a pain severity score of 8 out of 10. Patient’s symptoms are made worse and interfere with daily activities such as lifting, carrying, bending, standing /sitting for prolonged periods of time, ascending/descending stairs.

Plan: An overview of different treatment options were discussed with this patient including surgical and non-surgical modalities for amelioration of symptoms, such as chiropractic care/ physical therapy, epidural steroid injections and medication.

Patient has elected to proceed with physical therapy. Patient is to refrain from

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFany activity that exacerbates symptoms such as heavy lifting, carrying or bending and follow up in several weeks for a repeat evaluation.

Medical records from 07/14/YYYY to 06/18/YYYY are missing for review06/18/YYYY

XYZA Spine Specialist

Sukhbir XXXXX, M.D.

Follow-up visit for persistent low back pain:Chief complaint: Patient is complaining of low back pain, left lower extremity radiation despite lumbar spine epidural injections.

HPI: Patient presents today complaining of low back pain, lower extremity radiation with numbness, tingling and dysesthesias. Patient describes pain as being daily, constant and persistent with a pain severity score of 8 out of 10. Patient’s symptoms are made worse and interfere with daily activities such as lifting, carrying, bending, standing /sitting for prolonged periods of time, ascending/descending stairs.

Musculoskeletal physical examination: Spine examination:Inspection to percussion and palpation shows tenderness and spasms noted. There are restricted ranges of motion, 40 degrees of flexion (90° is normal), 15 degrees of extension (40° is normal), left and right turning to 15 degrees (60° is normal).

Plan: An overview of different treatment options were discussed with this patient including surgical and non-surgical modalities for amelioration of symptoms, such as chiropractic care/ physical therapy, epidural steroid injections and medication.

Patient would like to proceed with posterior spinal fusion and laminectomy L4- S1.

60-61

06/28/YYYY

XXXXX Diagnostic Imaging, PC

Richard XXXXX, M.D.

MRI lumbar spine:Clinical history: Posttraumatic low back pain and right leg pain.

Impression: Small central broad-based disc herniation, L4-L5 with mild to moderate bilateral facet arthropathy. Mild compression of the thecal sac and mild to moderate bilateral S1 root deformity is noted.

40

07/09/YYYY


Sukhbir XXXXX, M.D.

Follow-up visit for persistent low back pain:Chief complaint: Patient is complaining of low back pain, left lower extremity radiation despite lumbar spine epidural injections.

HPI: Patient presents today complaining of low back pain, lower extremity radiation with numbness, tingling and dysesthesias. Patient describes pain as being daily, constant and persistent with a pain severity score of 8 out of 10.

Plan: Patient would like to proceed with posterior spinal fusion and laminectomy L4- S1.Patient is to obtain an MR1 of the lumbar spine, refrain from any activity that exacerbates symptoms such as heavy lifting, carrying or bending and follow- up in several weeks for a repeat evaluation.

58-59

08/01/YYYY

ABCD/ XXXXX

Operative report for lumbar surgery:Pre- operative diagnosis: Lumbar radiculopathy, HNP and instability

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFMedical Center


Indication: Chronic pain with failure of conservative management with above diagnosis.Post- operative diagnosis: Lumbar radiculopathy, HNP, instability and severe neural compression

Operation: Posterolateral fusion L4/L5 Segmental pedicle fixation L4/L5 Lumbar laminectomy, L4/L5 Facetectomy and foraminotomy Morselized bone graft BMP implant bilateral Neurolysis L4/L5 Fluoroscopy

Findings: Instability and HNP

The patient was transferred to the recovery room in a stable condition. 08/09/YYYY



Follow-up visit status post lumbar surgery:Chief complaint: Patient is doing well post-operatively, however continues to have pain and symptoms consistent with pre-operative conditions.

HPI: Patient is doing well, with improvement of lumbar pain, however continues to have some residual pain and symptoms consistent with pre-operative conditions.

Musculoskeletal physical examination: Spine examination: Lumbar: Inspection to percussion and palpation reveals tenderness and spasms noted. Range of motion is restricted.

Diagnosis: Status post Posterior Spinal Fusion (PSF) laminectomy.

Diagnostic imaging: Lumbar X-rays taken today are satisfactory.

Impression/plan: Patient is doing well post- operatively with improvement, however, continues to have some residual pain and symptoms consistent with preoperative conditions. Patient is to attend physical therapy, refrain from any activity that exacerbates symptoms such as lifting, carrying, bending, twisting, and follow- up in several weeks for a repeat evaluation.

56-57

08/22/YYYY


Raj XXXX, M.D.

Follow-up visit for low back pain:She presents with a prescription from Dr. YYYY dated August 9, YYYY that allows for resumption of physical therapy for the lumbar spine but no flexion or extension of the lumbar spine at this time.

Chief complaints: The patient is complaining of low back pain which she describes as a pressure and she grades her pain as 3/10 in intensity.

Vocational history: The patient has not returned to work since her lumbar surgery.

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Musculoskeletal examination: Lumbar spine: A vertical midline surgical incision is clean, dry, and intact. There is tenderness to palpation in the area of the incision. Range of motion was deferred.

Assessment: Multiple lumbar spine disc herniations, status post lumbar fusion surgery on August 1, YYYY by Dr. YYYY, spine surgeon.

Recommendations: The patient will resume physical therapy three days per week. She was advised to follow-up with Dr. YYYY, spine surgeon, for management of her lumbar pathology. She can continue taking Tylenol as needed for her pain as long as that is okay with her regular medical doctor.

Disability: The patient is unable to work at this time. Her ultimate return to work clearance will come from Dr. YYYY, spine surgeon.

I will re-evaluate this patient in 4 weeks time.10/18/YYYY


Raj XXXX, M.D.

Follow-up visit for low back and left leg pain:Chief complaints: The patient continues to have low back pain and she notes intermittent numbness of the left leg. She states her pain has increased from a 3/10 to a 7/10 in intensity. However, she does note control of her pain when she takes Tylenol.

Recommendations: The patient will continue physical therapy three days per week. I will re-evaluate this patient in 6 weeks time.

Disability: The patient remains unable to work at this time. Her ultimate return to work clearance will come from Dr. YYYY, spine surgeon.

78-80

12/13/YYYY


Raj XXXX, M.D.

Follow-up visit for low back pain:Chief complaints: The patient continues to have low back pain with activity. However, she notes reduction of pain and grades it as a 3/10 in intensity today. She does note improvement in her pains with physical therapy.

Recommendations: The patient will continue physical therapy three days per week. I will re-evaluate this patient in 6 weeks time.


81-83

01/28/YYYY



Follow-up visit for low back pain:Chief complaint: Patient is doing well post-operatively, however continues to have pain and symptoms consistent with pre-operative conditions.

HPI: Patient doing well, with improvement of lumbar pain, however continues to have some residual pain and symptoms consistent with pre-operative conditions pain that is worse with lifting, carrying and bending, sitting, standing for prolonged periods.

Physical examination: Neurological: Sensation is decreased in the L4, L5 and S1 left nerve root distributions.

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Diagnostic imaging: Lumbar X- rays taken today are satisfactory.

Impression/plan: Patient is doing well post-operatively with improvement, however continues to have some residual pain and symptoms consistent with preoperative conditions. Patient is to attend physical therapy, refrain from any activity that exacerbates symptoms such as lifting, carrying, bending, twisting, and follow- up in several weeks for a repeat evaluation.

02/21/YYYY


Raj XXXX, M.D.

Follow-up visit for low back pain:Chief complaints: The patient continues to have low back pain which she grades as a 3/10 in intensity. She has noted one occasion where she felt some numbness in the left leg. Over the past 2 weeks she has noted anxiety and depression.

Recommendations: The patient will continue physical therapy but frequency will be decreased to two days per week. I am advising that she see a psychologist for further evaluation and management of her anxiety and depression.



84-86

04/17/YYYY


Raj XXXX, M.D.

Follow-up visit for low back pain and both legs weakness:Chief complaints: The patient continues to have low back pain which she grades as a 1/ 10 in intensity at rest but a 4/10 in intensity with activity. She now complains of numbness and weakness of both legs with tingling of the right leg. She continues to note anxiety and depression.

Recommendations: The patient will continue physical therapy two days per week. Disability: The patient remains unable to work at this time. Her ultimate return to work clearance will come from Dr. YYYY, spine surgeon.


87-89

05/01/YYYY



Follow-up visit for chronic low back pain:Chief complaint: Patient is follow- up chronic low back pain into lower extremities.

HPI: Patient doing well, with improvement of lumbar pain, however continues to have some residual pain and symptoms consistent with pre-operative conditions pain that is worse with lifting, carrying and bending, sitting, standing for prolonged periods.

Diagnostic imaging: Lumbar X-rays taken today are consistent with fusion

Impression/plan: Patient is doing well post-operatively with improvement, however continues to have some residual pain and symptoms consistent with preoperative conditions. Patient is to attend physical therapy, refrain from any

49-50

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFactivity that exacerbates symptoms such as lifting, carrying, bending, twisting, and follow-up in several weeks for a repeat evaluation.

08/22/YYYY- 06/27/YYYY

Multiple Providers

Summary of multiple physical therapy visits for low back pain:Total no of visits: 67Treatment area: Low backTreatment given: Therapeutic exercises, electrical stimulation, hot/ cold packs and massage.Prognosis: Poor. As of June 24, YYYY, she complained of persistent low back pain with associated tightness over her paravertebral muscles. Her last visit was on June 27, YYYY, during that time she reported that she is feeling better. She was discharged from the therapy and was asked to continue with her home exercises program.

*Reviewer’s comment: Multiple physical therapy visits have been combined and provided as a short summary.

105-173

06/27/YYYY


Raj XXXX, M.D.

Follow-up visit for low back pain and right leg weakness:Chief complaints: The patient continues to have low back pain which she grades as a 1/10 in intensity. She notes radiation of pain to the right lower extremity with numbness, tingling, and weakness of the right leg. She continues to note anxiety and depression.

Recommendations: At this point in time, I feel that the patient has plateaued and has reached maximal medical benefit from formal physical therapy and as such I will discontinue it. The patient was advised that she may continue to suffer from periodic exacerbations in her pain and limitations in her abilities. She was advised that when she has an exacerbation in her pain that she should continue with her home exercises and take over-the-counter medications on an as needed basis. She was also advised that if at any time these measures do not adequately control her exacerbations that she could contact us for the possibility of a re-evaluation and the possibility of a reinstitution of a formal physical therapy program.


She will be re-evaluated on an as needed basis.

90-92

08/02/YYYY



Follow-up visit for low back pain:Chief complaint: Patient is follow- up chronic low back pain into lower extremities.

HPI: Patient doing well, with improvement of lumbar pain, however continues to have some residual pain and symptoms consistent with pre-operative conditions pain that is worse with lifting, carrying and bending, sitting, standing for prolonged periods 7 out of 10 patients with depression issues after accident.Musculoskeletal physical examination: Spine examination:Inspection to percussion and palpation shows tenderness and spasms noted. There are restricted ranges of motion, 40 degrees of flexion, and 15 degrees of extension, left and right turning to 30 degrees.

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DATE PROVIDER OCCURRENCE/TREATMENT PDF REFImpression/plan: Patient is doing well post-operatively with improvement, however continues to have some residual pain and symptoms consistent with preoperative conditions. Patient is to home physical therapy; refrain from any activity that exacerbates symptoms such as lifting, carrying, bending, twisting, and follow- up in several weeks for a repeat evaluation.

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wiliam sepulvado€¦ · web viewlumbar spine strain/ sprain leading to multiple lumbar spine...

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