Medical Records Chronology of John Smith
Case No. 54-2017-CA-00000
DOB: 01/01/1965
DOL: 01/01/2016
Last updated: 01/01/2017
| DATE | FACILITY | OCCURRENCE/TREATMENT | NOTES |
|---|---|---|---|
| 2015/08/01 | Main Primary Care | Pt presents with c/o cough, sore throat, sinus congestion. | |
| 2016/01/01 | DATE OF LOSS | MVA | |
| 2016/01/01 | University Medical Center | Pt presents to ER via car post MVA this am with c/o lower back and neck pain with headache. Pain 8/10. Exam: Pain with palpation to left cervical and left lower paraspinal region. Imaging: X-ray of C-spine shows no abnormalities. X-ray of L-spine shows minimal degenerative changes at L4-5. Diagnosis: Cervical and Lumbosacral strain. Rx: Tizanidine 4mg; Lortab 5/500mg Plan: f/u with PCP within 2 days. |
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| 2016/01/06 | ABC Chiropractic | Pt presents for initial visit post 1/1/16 MVA. Pt c/o lower back pain. Pain 7/10. Exam: Lumbar area tender to palpation with spasm. Bruising to left leg. Imaging: X-ray of L-spine shows minimal degenerative changes at L4-5. Diagnosis: Lumbar strain/sprain. Plan: Chiropractic modalities 3 x per week for 4 weeks. |
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| 2015/01/07 | ABC Chiropractic | Pt presents for chiropractic modalities. Lower back pain 6/10. | |
| 2015/01/09 | ABC Chiropractic | Pt presents for chiropractic modalities. Lower back pain 5/10. | |
| 2016/01/11 | Orthopedic Clinic | Pt presents for initial visit with c/o lower back pain post 1/1/16 rear-end MVA. Pain 7/10. States immediately after accident he felt pain in neck and lower back. Neck pain has resolved. Review of hospital x-rays. Exam: Limited ROM with pain in lumbosacral area with spasm. Tender to palpation. Assessment: Acute Lumbar strain. Rx: Robaxin 500mg; Norco 5-325mg. Plan: Order MRI of L-spine. Order PT 3 times per week for 4 weeks. F/u in 2 weeks. |
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| 2016/01/12 | Imaging & Diagnostic Center | MRI of L-spine shows: 1. L4-5 diffuse annular disc herniation results in mild effacement at ventral thecal sac and mild bilateral neural foraminal narrowing. |
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| 2016/01/13 | Local Physical Therapy & Wellness | Pt presents for PT modalities. Pain 7/10. | |
| 2016/01/15 | Local Physical Therapy & Wellness | Pt presents for PT modalities. Pain 7/10. | |
| 2016/01/25 | Orthopedic Clinic | Pt presents for f/u visit with c/o lower back pain. Pain 8/10. PT does not seem to help. Review of 1/12/16 MRI of L-spine. Exam: No changes. Rx: Robaxin 500mg; Norco 5-325mg Plan: Referral to pain management. |
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| 2016/01/27 | Pain & Spine Management | Referred by Dr. Jones due to low back pain from 1/1/16 MVA. PT did not help. Pain continues with radiation into left leg. Pain 8/10. MRI from 1/12/16 shows L4-5 diffuse annular disc herniation. Exam: Tenderness to palpation over lumbosacral area with spasm. Plan: Recommend Epidural Steroid Injection at L4-5. Pt would like to proceed. |
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| 2016/01/28 | Pain & Spine Management | Procedure: Epidural Steroid Injection at L4-5. |