Orthopedic Case Studies

The claimant has a past medical history significant for obesity, diabetes mellitus, and hypertensive disorder.

A visit note from Robert Dean, MD (Internal Medicine), dated 05/11/2017, indicated that the claimant was recently in a motor vehicle accident and since then, she had persistent neck, left shoulder, and lower back pain. A review of the systems was positive for musculoskeletal pain, headache, and insomnia. She was diagnosed with cervicalgia, low thoracic rib head displacement, sacroiliitis, and sciatica. Continued therapy and a cervical spine epidural steroid injection were recommended.

An orthopedic evaluation report from Anthony Esposito, DO (Physical Medicine & Rehabilitation), dated 06/08/2017, indicated that the claimant reported neck and low back pain rated as 8/10. He stated that pain was aggravated by bending, climbing stairs, reaching, lying down, coughing, and looking up. Continued chiropractic therapy and MRIs of the

Dean, dated 06/14/2017, indicated that the claimant presented with neck pain, left shoulder pain, thoracic pain, lumbar pain, and headaches. She was restricted from prolonged sitting, standing, stooping, pushing, pulling, and lifting more than 10 pounds. She was relieved of work duties from 05/11/2017 - 07/06/2017.

A visit note from Dr. Esposito, dated 07/06/2017, indicated that the claimant presented with persistent neck and lower back pain that radiated to her left upper and left lower extremities. A short-term disability and a 30-day work release were recommended.

An attending physician statement completed by Ali Saifi, MD (Internal Medicine), dated 07/09/2017, indicated that the claimant was unable to perform any work due to constant pain and fatigue. She had complaints of numbness and sharp, burning pain. She was diagnosed with cervical, thoracic, and lumbar degenerative disc disease. She was relieved of work duties from 05/05/2017 - 08/03/2017 and 08/03/2017 -