DOI: 6/10/2014. The patient is a 38-year-old male assistant lead who sustained a work-related injury to his low back after lifting a 50-pound bag of soy crisp. Based on the progress report dated 03/03/16, the patient complains of pain from the lumbar spine radiating into the left leg and foot. Pain level is 7/10. The pain is constant and the symptoms have increased with the colder temperatures. The patient complains of tingling sensation on the outside of left leg. The pain increases with prolonged standing, sitting, and walking. He also complains of pain and inflammation on the right lower quadrant of his abdomen. He is following up with his primary care physician (PCP) for further diagnostics. Patient states he continues to experience symptoms …show more content…
Lordosis is decreased. Lasegue’s is equivocal, bilaterally. There is positive straight leg raise at 70 degrees, bilaterally, eliciting pain in L5-S1 dermatome distribution. Physical exam reveals tightness and spasm of the paraspinal musculature, bilaterally. There is hypoesthesia at the anterolateral aspect of foot and ankle of an incomplete nature noted at L5, and S1 dermatome level, bilaterally. There is weakness in the big toe dorsiflexor and big toe plantar flexor noted, bilaterally. There is facet joint tenderness at L3, L4, and L5 levels, bilaterally. There is muscle weakness and deficit over anterior abdominal wall. There is tenderness over left inguinal area with positive cough impulse. Diagnoses include lumbar spine strain/sprain rule out radiculitis/radiculopathy, secondary to herniated lumbar disc L3-4 and L4-5, status post prior laminectomy discectomy, 1998, with full recovery, left inguinal lymph nodes, symptoms of gastritis nonsteroidal anti-inflammatory medication (NSAIDS) related, left ankle strain/sprain rule out internal derangement and anxiety and depression. As of this report, the patient has reached MMI with 20% whole person impairment per AME report by Dr. Brourman, dated 1/18/16. Future medical care is indicated up to 20 sessions of physical therapy, medications, epidural steroid injections and possible lumbar spine