• Initial visit to primary care physician

    Visit Note from claimant's primary care physician
    states that patient appears with complaints of lower back pain afterhe lifted some heavy boxes in the warehouse of his job. Doctorperforms a number of objective tests that show that he is sensitive tolower back pain in the L5 region (which is most common). Doctor ordersan MRI of thoracic and lumbar spine prescribes ibuprofen and rest.
  • Period: to

    Jeff Smith vs. Ocla Corp

  • Review of MRI

    Dr. reviews MRI. Degeneration of of L4 and L5 consistent with overuse. Reccomends Physical therapy 3X per week
  • 1st week of physical therapy-Physical Therapist rates pain at 6/10

    Medical Report
  • 2nd week Physical Therapy

    Physical Therapist rates pain at 6/10
    complains of pain range of movement limited
  • 3rd Physical Therapist

    3/27 Complains that pain spiked after volleyball game
    3/29 range of movement slightly improving patient still complains of pain
  • April Visit

    patient appears at his primary care physician for evaluation of progress. State no real help from physical therapy and pain is still at 6/10. Doctor then will prescribe less "conservative" treatment (tx) such as steroid injections to the lumbar
  • Steroid Injection

  • May visit to Primary Care Physician

    Steroid shot provided relief pain rate 4/10
  • June visit Primary Care Physician

    patient did not show for June appointment
  • Car Accident

    Patient appears in the emergency room no head injury did not complain of back injury. Doctor orders MRI. Dr. Reviews MRI thoracic spine and back are "normal"
  • July visit to Primary Care Physician

    States the pain is subsiding in neck and knee still having pain in back. Doctor prescribes steroid injection.
  • Retains attorney

  • August visit to Primary care physician

    Patient complains that he did not receive any relief from the steroid injetion. Pain at 6/10 and states that back injury is from the motor vehicle accident. Doctor presribes Lortab and steroid injection discusses surgical option if pain continues.
  • August pain management appointment

    3rd steroid injection
  • September primary care physicain appointment

    lower back paincontinues at 6/10 from
    "motor vehicle accident." Pain resistent to conservative treatment. prescribes 2nd MRI of lumbar spine. Reviews MRI which indicates cont degeneration of lumbar spine at L4-L5. Discusses lumbar fusion withpatient. Pt believes that this is in his best interest. Dr refers ptto neurosurgeon, cont Lortab
  • Surgery

    fusion of L4-L5. Reccomends pnysical therapy 3x per week for 6 weeks;
    Lortab for pain
  • 1st week physical therapy

    Patient complains of pain, range of movement low
  • 2nd week phyiscal therapy

    Patient continues to make progess toward goals.
    Range of movement low
  • Week 3 physical therapy

    Pt continues to make progess toward goals.
    Range of motion improving.
  • Discharge Summary

    Patientt made progress on all physical therapy
    modalities. Discharged to home exercise.
  • January primary care visit

    Pt states pain is still at 5/10 and that he continues to do
    home exercise. Orders Xray lumbar spine. Xray shows spinal fusion in
    proper placement. No additional issues identified in radiology.