Jose XXXXX DOB: 11/25/YYYY General Instructions€¦ · Jose XXXXX DOB: 11/25/YYYY 6 of 21 DATE...

Jose XXXXX DOB: 11/25/YYYY

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MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW

General Instructions:

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

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

Reviewer’s Comments:Comments on contradicting information and misinterpretations in the medical records, illegiblehandwritten notes, missing records, clarifications needed etc. are given in italics and red font color andwill 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 “IllegibleNotes” in the heading of the particular consultation/report.

Specific Instructions:1. Medical chronology focuses on the MVA on 05/24/YYYY, the resulting injuries and their treatment.2. Physical therapy visits have been combined and a summary of the visits is provided. The initial and

final physical therapy visits have been captured in detail3. Missing records have been mentioned in the Reviewer’s Comment.4. Case specific details have been highlighted.5. A snap shot of the provider is given when the provider’s name is illegible.


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Injury Report

Date of Injury: 05/24/YYYY

PARAMETER DETAILS PDF REFInjuries and SignificantMedical Condition BeforeAccident

Past medical history: Low back painPast surgical history: He underwent microdiscectomy in YYYY for Lowback pain.

424

Injuries directly as a result ofaccident?

Open fracture of the left hand. Left ankle sprain. Contusion of left leg with concern for compartment syndrome. Right shoulder and hand pain with weakness Avulsion fracture left medial malleolus healed second metacarpal neck

fracture. Right shoulder impingement. Left lumbar radiculopathy with left leg radiating symptoms and lower

extremity dysesthesia Right index finger persistent flexor tendon tenosynovitis status post

injection on December 4, YYYY. Right index finger metacarpophalangeal (MP) joint radial collateral

ligament laxity. L5-S1 severe disc injury with back pain syndrome

445-447, 234,338-346, 5-9,420-421, 208-209

Surgery underwent as a resultof the accident?

05/26/YYYY: Open reduction and pin fixation for an open index fingermetacarpal fracture. (Operative report is unavailable)11/28/YYYY: Epidural injection at L5-S101/09/YYYY: Epidural injection at L5-S106/01/YYYY: L5-S1 left sided laminectomy12/04/YYYY: Tendon sheath injected into the right index finger04/28/YYYY: Transforaminal reexploration of previous laminectomy,facetectomy, diskectomy, decompression of nerve root followed byinterbody fusion and posterolateral fusion utilizing pedicle screws and rods.05/01/YYYY: L5-S1 posterior lumbar interbody fusion

5-9, 44-45, 51-52, 63-64, 420-421, 424-425

Did any prior injury/medicalcondition aggravate after theaccident?

Noted to have a prior history of low back pain, however there are no priorrecords to review

424

Did any new injuries/medicalcondition (not related to theaccident) develop?

None

Did patient return to work? Yes12/04/YYYY: He is self employed performing some painting and lightconstruction works.

5

Impact of Injury onADLs/Quality of Life?

Extreme difficulty: Recreation, sports, squatting, walking 2 blocks,walking a mile, standing for 1 hour, running on even ground and unevenground, making sharp turns while running fast and hopping.Quite a bit of difficulty: Getting into or out of the bath, walking betweenrooms, putting on socks, lifting an object, performing light activities,

163-168, 267-270


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performing heavy activities, getting into or out of car and going up or down10 stairs.Moderate difficulty: Usual household and school activities.The pain increases with walking or standing, flexing and extending theknee, climbing or descending stairs, giving way and uses a cane or walkerfor balancing.

Disability (if any) Physician has not mentioned anything about disabilityMedical Condition of Patientas per last available records(any treatment/surgery thatthey will need)

05/01/YYYY: Discharged after hospitalization for L5-S1 posterior lumbarinterbody fusion. The patient was able to ambulate up to 900 feet with thehelp of a walker.

424-425

Missing Medical Records

Patient History

Past Medical History: Denies any past medical history (PDF REF 5)

Surgical History: Appendectomy (PDF REF 442)

Prior occupational history: He works as a carpenter. He lost time from work due to the accident(PDF REF 5, 269)

Current occupational history: He is currently self-employed performing some painting andlight construction work. (PDF REF 5)

Family History: Mother had diabetes mellitus and hypertension (PDF REF 442)

What Recordsare Needed

Hospital/Medical Provider

Date/TimePeriod

Why we need therecords?

Is Record MissingConfirmatory orProbable?

Hint/Clue thatrecords aremissing

EMS report Unknown 05/24/YYYY To know thecondition of thepatient

Confirmatory PDF REF: 453-455

Hospital records XXXXX 05/25/YYYY-05/31/YYYY

To know theprognosis of thepatient


Hand therapyrecords

XXXXX SurgicalCenter

4 months (Dateis unknown)



Medical records Unknown 06/01/YYYY-06/14/YYYY


Probable -

TCR - 05/24/YYYY To know themechanism of theinjury

Probable -


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Social History: He does smokes 6 cigarettes per day. He is a social drinker of alcohol. He issingle and has had three children. (PDF REF 6, 270)

Allergy: No known drug allergies. (PDF REF 5)

Detailed Chronology

DATE PROVIDER OCCURRENCE/TREATMENT PDF REF

05/24/YYYY XXXXXMedical Center

DonovanXXXXX, RN

@1725 hrs – Trauma flow sheet:GCS: 15Vitals: BP: 154/101, heart rate: 97, respiratory rate: 16, pulse oxymetry: 100% onroom air which is adequate.Patient arrived with full spine precaution. Patient complains of back pain and leftlower extremity pain.

*Reviewer’s comment: EMS report is unavailable for review; hence the patient’scondition at the scene of accident is unknown.

Pain: 10/10The patient has received Fentanyl as well as Dilaudid for his pain.

@1728 hrs – Nurse notes:Patient driver of motor cycle. Patient wearing helmet. Patient travelling 35 mph,patient complains of lower back pain. Patient in full cervical spine upon arrival.Moaning in pain. Patient given Morphine enroute.

448, 453-455


Dan XXXXX,M.D.

@1951 hrs - Emergency room record for MVA:This is a 36-year-old male who was the helmeted rider of a motorcycle traveling atapproximately 35 miles an hour when it collided with a vehicle. The patient wasejected off the motorcycle. He did not lose consciousness. His main complaint is thatof right hand pain, left leg pain and back pain. In the field, he was placed in fullcervical spine precautions and transported to the medical center for furtherassessment and evaluation.

Physical exam:General: Patient lying in the gurney in mild distress secondary to pain.Back: He has some tenderness to palpation in the lower thoracic and mid lumbarregions.Extremities: The patient has pain and what appears to be a deformity to the righthand. There is a puncture wound to the dorsum of the right hand overlying thesecond metacarpal distally. The patient has abrasions to the left leg. He hasbimalleolar tenderness to the left ankle. His pain was with dorsi and plantar flexion.The patient has exquisite tenderness to palpation of the lateral compartment of theleft leg. Initially it was soft. Hematoma was noted.Skin: Warm and dry with abrasions as noted above to the left leg as well as apuncture wound to the dorsum of the right hand.

445-447,450


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Radiological investigation reports:Left tibia/fibula shows mild posterior subluxation of tibia with regard to the talus,but no evidence of fracture.Right hand series reveals a second and a fourth metacarpal fracture.Left ankle series reveals mild posterior subluxation of the tibia with regard to thetalus.CT of the lumbar spine without contrast shows no evidence of fracture ordislocation.CT of the thoracic spine without contrast reveals minor degenerative changes, but noevidence of fracture or subluxation.CT abdomen and pelvis without contrast reveals no solid organ injury or fracture. CTcervical spine shows no evidence of fracture or dislocation. He may have anarachnoid cyst.AP pelvis shows no evidence of fracture or subluxation.AP chest X-ray shows no evidence of an acute cardiopulmonary process.

*Reviewer’s comment: The report for the any of the above radiologicalinvestigations is not available; hence the severity and the extent of damage could notbe fully understood.

Emergency department course and treatment/discussion: The patient hasreceived Fentanyl as well as Dilaudid for his pain. Upon return to the ER, Ireexamined the patient and noted the puncture wound over the hand. This wasconsistent with a type I open fracture of the right hand. The patient has been givenAncef 1 gram IV. Dr. Danielpour of Hand Surgery has been notified by the traumateam and will likely operate on this patient tomorrow.Though there is no evidence of a fracture on the plain radiography, I am concernedabout this patient’s left leg. He continues to have pain, especially with passive rangeof motion of the left ankle. It is difficult to discern whether this pain is beingappreciated by the patient at the ankle or at the left leg. He does not have anyevidence of fracture, but I am still concerned about the possibility of compartmentsyndrome. At this time he has strong distal pulses. He has no paresthesias and nocolor change. Nonetheless, I have spoken with Dr. Justin Saliman who has kindlyagreed to examine the patient. At the time, the patient will be admitted to the surgicalteam for serial.

Diagnoses: Open fracture of the right hand. Left ankle sprain. Contusion of left leg with concern for compartment syndrome. Back injury.

Disposition: Admit to surgical team.

Condition upon discharge from emergency department: Fair.


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*Reviewer’s comment: The further progress of the patient, hospitalization record,operative record and discharge summary are unavailable for review. Hence we donot have the complete details pertaining to the treatment that was rendered for hisright hand fracture and left tibial subluxation.*Reviewer’s comment: Records from 05/25/YYYY-06/14/YYYY is unavailable. Hencethe complete details on all the different procedures that the patient underwent in theintervening period are not known.


CharlesXXXXX, M.D.

Order for physical therapy for left leg crush injury:

*Reviewer’s comment: Office visit of Dr. Charles XXXXX is unavailable for review;hence the reason for the visit, treatment and the plan is unknown.

144

06/19/YYYY XXXXXPhysicalTherapy

ElizabethXXXXX, PT,DPT

Initial physical therapy evaluation for left lower leg crush injury:Patient’s chief complaint is pain in left knee and ankle. Aggravating factors includestanding 10 minutes, walking 5 minutes, negotiating stairs, in/out of chair, car andbed. Donning/doffing shoes/socks and pants.

How often do you experience pain: ConstantlyNature of your symptoms: Sharp, shooting, numb and tinglingIntensity: 8-10

Lower extremity functional scale:Extreme difficulty: Recreation, sports, squatting, walking 2 blocks, walking a mile,standing for 1 hour, running on even ground and uneven ground, making sharp turnswhile running fast and hopping.Quite a bit of difficulty: Getting into or out of the bath, walking between rooms,putting on socks, lifting an object, performing light activities, performing heavyactivities, getting into or out of car and going up or down 10 stairs.Moderate difficulty: Usual house hold and school activities.

Primary impairments:Limited ankle mid knee range of motion, weakness in lower extremity musculature.Edema in left lower extremity: gait deviations include decreased weight beating ontoleft lower extremity. Decrease ankle dorsiflexion in swing phase, and decrease hipextension in terminal stance.

Functional limitations:Standing tolerance 10 minutes with painGait endurance to 5 minutes with assistive device with painAscend/descend 1-2 steps with painSit to stand with pain and asymmetrical weight bearingTransfers in/out of car and bed with painDressing with pain (donning/doffing shoes, socks, and pants)

Disabilities: Patient unable to perform work, recreational and duties as a fatherwithout pain and difficulty.

145, 163-168


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Treatment plan: 2-3 times per week for 4-6 weeks.Joint mobilization, soft tissue mobilization/myofascial release, neuro-muscular re-education, therapeutic exercise, posture/back education, gait balance, modalities,tapping and home exercise program (HEP).

06/22/YYYY-07/06/YYYY

XXXXXPhysicalTherapy

Summary of multiple physical therapy visits for left knee and ankle pain:Total number of visits: 5

Areas treated: Left lower leg and ankle

Outcome as on 07/06/YYYY: Patient reports he feels good after last visit, his ankleis getting a lot better but knee still has pain in back, unable to kneel or bend his knee,his swelling is getting better as well.

*Reviewer’s comment: Multiple physical therapy visits have been combined and asummary provided.

158-162,143


E. XXXXX,DPT

Final physical therapy visit for left knee and ankle pain:Patient reports his ankle is doing better overall and he is able to walk more. Howeverhis knee still hurts but slowly improving. Feels no improvement in pain but after lastvisit he feels slightly better with knee.

Pre-treatment findings:Gait: Mild antalgic gaitAnkle plantar flexion: Limited by 25% with pain.Ankle dorsi flexion: Limited by 25% with pain.Knees: Symmetrical. Positive in posterior knee.

Intervention:Passive range of motion in ankle and knee for 10 times.CR to improve ankle dorsi flexion and plantar flexionUltra sound to left post kneeTherapeutic exercises

Assessment: Patient had increased ankle ROM but no change in knee ROM aftertreatment. Able to begin bike with resistance.

*Reviewer’s comment: Discharge summary from physical therapy visit isunavailable hence the final visit has been captured in detail

157

08/07/YYYY Scott L.XXXXX, M.D.

Office visit for left ankle avulsion fracture: Illegible notesPatient now has swelling at left ankle, numbness in shin. Stiffness in right hand-______ PT. left knee pain, popping, worse with squatting up.

Physical exam:Tenderness over left ankle in medial malleolus. Tenderness over left knee joint, haspositive for swelling in knee, ankle and right hand. Decreased grip and strength.Tenderness over metacarpal joint near interphalangeal joint.

Assessment: Avulsion fracture, medial malleolus healed, second metacarpal neck

234


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fracture.

Plan: PT/hand therapy, wear off brace. Consider MRI of left knee. Follow up in 4weeks. Home exercises.

09/07/YYYY Scott L.XXXXX, M.D.

Follow-up visit for left ankle avulsion fracture: Illegible notesPatient continues to have left knee pain and stiffness. Walks with limp, positive_______, occasional giving way. Left ankle intermittent pain, swelling withprolonged standing/walking. Numbness anterior left shin, right hand improved withPT, occasional pain and paresthesia.

Physical exam:Tender left knee joint has positive McMurray. 0-120°. Positive swelling in left kneeand right hand. Significant tenderness in right hand, tender left medial ankle andpositive swelling.

Plan: Continue hand therapy once a week for 4 more weeks. Increased strength.MRI left knee. PT twice a week for 4 weeks, left knee/ankle.

233, 301

09/14/YYYY CaliforniaRadiology

J. BruceXXXXX, M.D.

MRI of left knee:Indication: Pain and limited range of motion. Question of meniscal tear.

Impression: Normal internal architecture of the left knee.

306


NormanXXXXX, PT

Initial physical therapy evaluation for left knee and ankle pain:Patient reports an onset of significant left knee pain and left ankle pain due to apersonal injury which occurred on 05/24/YYYY. He stated that he injured his leftknee and left ankle after the motorcycle he was riding struck a car that came from anopposite direction that had made a left turn on an intersection while there was still agreen traffic light. He said that he tried to avoid the car by applying break on hismotorbike and swerved towards the right lane to avoid collision, then collided withthe car. He said that he flipped over the car injuring the left knee, left ankle andlower back. Due to the impairment caused by the injury, patient was unable tocontinue work-related duties at prior level of function. The patient complains ofconstant burning- sharp left knee and intermittent sore achy pain to left ankle. Theknee pain is level is described as 8/10, and the left ankle pain is described as a 7 outof a scale of ten. Currently, patient has been referred for physical therapy for painmanagement and functional restoration.

Pain descriptionAggravating factors: Standing for long period, walking for long period, stairs,bending, squatting, kneeling, and sitting for long period and ADL’s.Relieving factors: Rest, elevation, ice pack, massage and medications.

Objective:Active range of motion (ROM) of knee:

Motion Right LeftFlexion 115° 75°Extension 0° -15°

25-27


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Active ROM of ankle:Motion Right LeftPlantar Flexion 115° 75°Dorsi flexion 5° -10°Inversion/eversion 45/10° 15/5°

KneeManual muscle testing LeftQuadriceps 4-/5Hamstrings 3-/5Gastrocnemius 4-/5Tibialis Anterior 3-/5Peroneus 3-/5

Gait analysis:• Shortened step length.• Asymmetrical stride length.• Decreased cadence.• Decreased knee flexion during initial swing, bilaterally.• Decreased knee extension during terminal swing, bilaterally.• Decreased hip extension during terminal stance.

Special test: Medial and lateral stress test: Positive in left.

Palpation:Tenderness to medial and lateral joint line of left knee, (±) mild swelling to left knee;tightness to left hamstrings and left quadriceps femoris more in right. Positiveswelling to left lateral ankle/foot, tenderness to lateral malleolus of left ankle.Tightness to left gastrosoleus muscle.

Assessment:Descriptions:• Impaired functional capacity secondary to personal injury.• Limitations with activities of daily living due to pain and diminished strength andrange of motion.• Subjective and objective deficits may be addressed with physical therapyintervention.• Patient demonstrates good motivation towards physical therapy.• Good rehabilitation potential to meet physical therapy goals.

Problems:• Pain limits capacity to perform ADL’s.• Decreased range of motion limits capacity to perform activities of daily living.• Impaired strength limits functional capacity.

Treatment plan


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Physical therapy knee program consisting of:• Therapeutic exercise - Promote strength of knee musculature,• Body mechanics/Ergonomics training - Proper positioning and lifting strategies.• Myofascial release and flexibility as needed - Soft tissue stretching improve rangeof motion.• Soft tissue mobilization and modalities as needed - Pain control and improve tissuehealing time.• Patient education - Promote understanding and knowledge of injury-related issues.• Home exercise program prove compliance and independence with therapeuticexercises.

09/27/YYYY JacobXXXXX, M.D.

Comprehensive Orthopedic Consultation Report for right shoulder, left leg andlow back pain: Incomplete notesOn May 24, YYYY, patient was traveling on a motorcycle on a surface street, whena vehicle made a left turn in front of him causing a collision and causing him to falloff of the motorcycle. He experienced pain to his right shoulder, right hand, leftankle, left leg, left knee and lower back, with pain radiating into his legs, withassociated numbness to his left leg. He suffered road-rash throughout the left leg andright hand. The paramedics arrived and he was transported to the emergency room.

Treatment: He was initially evaluated at Cedar Sinai. He was examined and X-rayswere obtained of the right hand, MRI studies were obtained. Surgery was performedto his right hand the following day. A cast was placed to his right hand and he wasprescribed medications. He was hospitalized for six nights.

Left knee/leg: The patient is experiencing constant, pain in the left knee and leg.The pain increases with walking or standing, flexing and extending the knee,climbing or descending stairs, giving way and uses a cane or walker for balancing.Additionally, there is popping, and clicking.

Left ankle: The patient is experiencing constant, pain in the left ankle. The painincreases with standing or walking. There is a feeling of instability in the ankle. Thepatient notes popping and grinding.

Current complaints:Right shoulder: The patient is experiencing constant pain in the right shoulder. Thepain increases with rotation, torquing motion, reaching over the head, lifting,carrying, pushing, pulling, abduction, or external rotation. The patient notesinstability of the shoulder as well as clicking, popping or grinding sensations.

Right hand: The patient is experiencing constant pain in right hand. The painincreases with repetitive flexion, grasping, gripping, pushing, pulling and whenopening jars and bottles.

Lower back: The patient is experiencing frequent lower back pain. The pain radiatesinto the legs. The pain increases with sitting, walking or standing, forward bending,squatting, climbing or descending stairs, twisting, turning and forceful pushing andpulling.

267-270,137-138


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Left knee/leg: The patient is experiencing constant pain in the left leg and leg. Thepain increase with walking or standing, flexing and extending the knee, climbing ordescending stairs, twisting, turning and forceful pushing and pulling.

Left ankle: The patient is experiencing constant pain in the left ankle. The painincreases with standing or walking. There is a feeling of instability in the ankle. Thepatient notes popping and grinding.

*Reviewer’s comment: Physical examination, assessment and plan is unavailable forreview


J. BruceXXXXX, M.D.

MRI of lumbar spine:Indication: Post traumatic low back pain and lower extremity dysesthesia.

Impression: Left eccentric annular prominence distorts the thecal sac at the origin of the

budding left L4 root at L3-L4 Median protrusion dissects caudally behind the posterior longitudinal ligament

(PLL) in the midline at L4-5. Focal annular protrusion into the left lateral recess distorts the budding left S1

root at L5-S1

208-209


J. BruceXXXXX, M.D.

MRI of right shoulder:Indication: Posttraumatic pain and limited range of motion

Impression: Type III acromion and synovial hypertrophy impingement Tendinopathy and intrasubstance delamination anterior leading edge SST Focal partial 60% tear of the articular surface main body and anterior leading

edge SST

210-211

10/09/YYYY AaronXXXXX, M.D.

LawrenceXXXXX, M.D.

Electromyography (EMG) and nerve conduction study (NCS) of bilateral lowerextremities:Impression: Normal nerve conduction study. No evidence of peripheral neuropathy was

noted at any level in the bilateral lower extremities Normal EMG: No evidence of active lumbar radiculopathy was noted in the

bilateral lower extremities

199-205

10/25/YYYY XXXXX

JacobXXXXX, M.D.

Prescription record for Naproxen 500 mg and Hydrocodone 5/325 mg 134

11/27/YYYY LawrenceXXXXX, M.D.

Initial pain management consultation report for low back pain and rightshoulder pain:Chief complaints: Low back pain with left leg radiating symptoms Right hand pain with weakness Right shoulder pain

338-346,197-198,214


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Left ankle pain

The patient reports that he sustained a motor vehicle versus motorcycle accident onMay 24, YYYY. He reports that he was traveling about 25-30 miles an hour when hewas struck and thrown to the pavement. He was brought immediately to the XXXXXHospital where he was admitted for one week. He presented with left lowerextremity swelling and right hand second metacarpal fracture. He underwent ORIFof the second metacarpal fracture with pin removal approximately five to six weekslater. During the course of this hospitalization at Cedars-Sinai, he reports that his leftleg was swollen. He was seen by trauma surgeons where there was consideration ofperforming a fasciotomy. The swelling gradually resolved with conservativetreatment and elevation. Following discharge, he has been seen by orthopedicsurgeons, Dr. Rosenzweig and more recently Dr. Tauber. He has continued inphysical therapy. He is referred to the undersigned in consideration of lumbarepidural steroid injection with findings of persistent back and left leg radiatingsymptoms.

Present pain complaints: Low back. He has 8/10 constant pain. The pain is throbbing, radiates primarily

down the left lower extremity posteriorly to his foot with numbness, tingling,and weakness. Pain is aggravated by walking, bending, sitting, and lifting.

Right hand. He has intermittent right hand pain that is described as throbbing,aggravated by grasping and lifting. There is right hand weakness.

Right shoulder. He has 5/10 constant pain. No radiation. Pain is aggravated bylifting and moving his arm.

Left ankle. He has 7/10 aching discomfort. Pain is aggravated by walking andweightbearing.

Physical exam:Appearance: He is over weight in obvious discomfort.Heel-to toe walk: Performed with difficulty.

Cervical spine examination:Head carriage/lordosis: MidlineCervical:

Range of motion Right Left ExpectedLateral rotation 70 70 70Lateral flexion 30 30 30Extension 60 60 60Flexion 60 60 60

Upper extremity examination:Tenderness: Right hand dorsal tendernessShoulder

Range of motion Right Left ExpectedAbduction 170 180 180Forward Flexion 170 180 180


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Internal Rotation 90 90 90 90External Rotation 90 90 90 90Crossed Shoulder Adduction 40 40 40Apley Scratch Test L3 L3 T7-9 T7-9

Impingement sign: Positive in right

JAMAR:Right(Dominant): 78/78/76Left: 100/105/105

Lumbar spine examination:Tenderness/trigger points: Left paralumbar tenderness.

Sciatic nerve root tension tests:Sciatic Notch Tenderness: Positive in leftLasegue’s Sign: Positive in leftBowstring Sign: Positive in leftStraight Leg Raise: Positive in leftThere is positive left Lasegue, increased by left foot dorsiflexion and relieved byknee flexion.Lumbar

Range of motion Right Left ExpectedLateral bend 20 20 30/30Flexion 70 70 70Extension 20 20 30

There is pain on flexion, extension of lumbar spine.Sensory testing lower extremities: Hypoesthesia in the left L5-S1 dermatomeReflex: Left ankle: 1+

Diagnostic impression: Status post right second metacarpal fracture with open reduction internal fixation

and pin removal and residuals Right shoulder impingement Left lumbar radiculopathy History of near left leg compartment syndrome - resolved

Discussion:He presented with right second metacarpal fracture and left leg swelling with nearcompartment syndrome. He was hospitalized for one week. He has had persistentresiduals of pain in the right hand, shoulder, and primarily low back with left legradiating symptoms. He has evidence of L4-5 disc protrusion as well as a focal discprotrusion with the left L5-S1 disc recess distorting the S1 nerve root. There arepersistent sciatic symptoms and findings of radiculopathy. In light of the evidence oflumbar radiculopathy, he is felt to be a candidate for lumbar epidural steroidtreatment at the left L5-S1 level. The request for epidural steroid is placed to


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facilitate earlier pain relief and allow the patient to more effectively participate inrehab.

Plan: Authorization request is placed for left L5-S1 epidural steroid injection for

palliative treatment of left lumbar radiculitis. He indicated he wanted to proceedin light of the severe left-sided sciatic symptoms. The estimated cost of thelumbar epidural steroid injection including facility fees is $6000. The injectionmay be repeated x 2 if there is substantial improvement following the initialinjection for total estimated cost of $18,000.

Patient remains under the care of orthopedic surgeon, Dr. Tauber for findings ofright shoulder impingement.

11/28/YYYY WilshireXXXXX

LawrenceXXXXX, M.D.

Procedure report of L5-S1 interlaminar epidural, lumbar epidurogram withinterpretation:Pre and post operative diagnosis: L5-S1 disc disruption with left lumbar radiculitis

Procedure performed: L5-S1 interlaminar epidural Lumbar epidurogram with interpretation

Indications for procedure: The patient is suffering from L5-S1 disc disruption withleft lumbar radiculitis. He is admitted for an epidural steroid injection.

44-45, 337

11/29/YYYY XXXXX

JacobXXXXX, M.D.

Prescription record for Naproxen 500 mg and Cyclobenzaprine 10 mg 130

11/26/YYYY-12/03/YYYY

XXXXXPhysicalTherapy

Summary of multiple physical therapy visits for low back pain, left knee andankle pain:Total number of visits: 21

Areas treated: Left knee and ankle

Outcome as on 11/29/YYYY: Pain is improving. Progress is steady. Continue planof care.*Reviewer’s comment: Multiple physical therapy visits have been combined and asummary provided.

19-24


Final physical therapy for low back pain, left knee and ankle pain:Subjective: Improving

Assessment: Decreased symptoms

Plan: Continue PT per plan of care.

*Reviewer’s comment: Discharge summary is unavailable for review, hencecaptured the final visit in detail

22

12/27/YYYY XXXXX Prescription record for Naproxen 500 mg and Hydrocodone 5/325 mg 123


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JacobXXXXX, M.D.

01/09/YYYY WilshireXXXXX

LawrenceXXXXX, M.D.

Procedure report L5-S1 interlaminar epidural, lumbar epidurogram withinterpretation:Pre and post operative diagnosis: L5-S1 discogenic disease

Procedures performed: L5-S1 interlaminar epidural steroid injection Lumbar epidurogram with interpretation

51-52, 384

01/31/YYYY XXXXX

JacobXXXXX, M.D.


01/31/YYYY JacobXXXXX, M.D.

Correspondence regarding comprehensive orthopedic evaluation for low backpain:The patient reports that he has not improved. In light of this, I am recommending hebe seen in neurosurgical consultation by Dr. Obukhoff. The patient will return to thisoffice in one month for follow-up.

266

02/28/YYYY XXXXX

JacobXXXXX, M.D.


03/27/YYYY Center forXXXXX

SergeXXXXX, M.D.

Neurosurgeon consultation report for low back pain:Patient injured his back and was managed conservatively with epidural steroidinjection and physical therapy with no improvement. The main problem is lowerback pain going down his left leg all the way into his foot, numbness and tinglingwith some weakness in his foot on the left side.

Physical exam:General: The patient is a heavy built gentleman moderately overweight, looksaccording to his age.Lower extremities: Exam reveals diminished sensation at S1 dermatomaldistribution on the left side where the patient is experiencing most of the pain.Grossly positive straight leg raising on the left side from neutral position and up andon the right side from 35 degrees. Weakness on the left side on plantar anddorsiflexion to 4/5. Loss of ankle jerk reflex on the left side, and on the right side, itis 1+ and knee reflex is 3+.

Discussion and recommendationsTaking into account the lack of improvement from conservative treatment and it hasbeen almost a year since the accident. I am recommending this patient L5-S1, left-sided microdiskectomy. This is an official request for surgery authorization. The costof the surgery can run up to $40,000 to $45,000 including hospital fee.

81-82

04/11/YYYY XXXXX

JacobXXXXX, M.D.



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SergeXXXXX, M.D.

Correspondence to Dr. Jacob XXXXX regarding neurosurgeon consultation forlow back pain:The patient is still having predominantly left-sided S1 radiculopathy, although hisMRI scan is consistent with 3- level disk problem.

My recommendation was to offer him L5-S1 microdiskectomy on the left side. Iexplained to the patient the nature of the procedure.

80

05/29/YYYY XXXXXSurgery Center

Office visit for pre operative clearance:Complains of low back pain.Came for preoperative clearance.Plan: Labs ordered.

83

05/31/YYYY United MedicalImagingXXXXX

PatriciaXXXXX, M.D.

X-ray of chest:History: Pre-operative chest X-ray for lumbar spine surgery

Impression: Normal chest X-ray

79

06/01/YYYY XXXXXPhysiciansSurgicalCenter, LLC

SergeXXXXX, M.D.

JacobXXXXX, M.D.

Operative report of L5-S1 left sided laminectomy:Pre and post diagnosis: L5-S1 disc herniation and left leg radiculopathy

Procedures performed: Morbidly obese patient L5-S1 left sided hemilaminectomy,medial facetectomy followed by microdiscectomy with decompression of nerve rootfollowed by a steroid injection in multiple locations for postoperative pain control.

Indications: The patient sustained an injury and after the injury, developedpersistent left leg pain syndrome consistent with SI dermatomal distribution and wasdiagnosed with disc herniation.

Findings: Disc herniation with compression of lateral recess was found at L5-S1 onthe left side and centrally with a broad tear of posterior longitudinal ligament.

63-64

06/01/YYYY-06/04/YYYY

XXXXXPhysiciansSurgicalCenter, LLC

Other related records:Anesthesia record, PACU record, nurse notes, product label, discharge instruction,post operative call, orders, pathology report and checklist.

*Reviewer’s comment: These records have been reviewed and combined

65-70, 85-90, 62


SergeXXXXX, M.D.

Correspondence to Dr. Tauber regarding post surgery neurologicalconsultation:It has been 4 days since his surgery, microdiskectomy at L5-S1. The patient has donevery well. He noticed significant improvement in his leg pain and only someachiness in the left leg still persists, although the pain which used to be throbbingand going down into his foot has improved. His dressing is dry. I removed the upperdressing. I am recommending the patient to do as much walking as he can. I will seehim in about 3 weeks for his next followup. The patient is status postmicrodiskectomy.

262

06/26/YYYY Serge Referral report for physical therapy – status post lumbar spine surgery 249


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XXXXX, M.D.


SergeXXXXX, M.D.

Correspondence to Dr. Tauber regarding post surgery neurologicalconsultation:It has been 3 weeks since his surgery, microdiskectomy, radiculopathy, although hefeels some tingling in his leg and some lower back pain with occasional shootingpain in the lower back in the surgery site. His wound has healed primarily. He isfully ambulatory. At this point, I am making a request for aquatic therapy. I amrecommending aquatic therapy for two times a week for six weeks. I will see thepatient in six weeks. The patient is status post microdiskectomy with improvement.

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07/31/YYYY SergeXXXXX, M.D.

Correspondence to Dr. Tauber regarding post surgery neurologicalconsultation:The patient had surgery about 2 months ago when he had microdiskectomy for hispersistent radiculopathy. The symptoms of radiculopathy have improveddramatically, although the patient still has intermittent numbness in his foot on theright side which is a result of the nerve root compression which was prior to thesurgery. He is still complaining of lower back pain particularly after prolongedsitting or lying down and that is related to the injury to his disks. The patient isknown to have 3 degenerative disks and there is also pain syndrome. Althoughtaking into account the improvement of radiculopathy, my recommendation for thispatient is to continue to do aquatic therapy and try to control his weight. He is asignificantly overweight gentleman. The patient received some medications ofIbuprofen and Norco 5/325 mg which he takes on as needed basis. I will see him inabout the next 6 weeks for his next followup. The patient is status postmicrodiskectomy with improvement of radiculopathy and continuation of some backpain syndrome. The patient’s neurological evaluation revealed reflexes 2-1-bilaterally on both lower extremities, symmetrical. Diminished sensation on the rightside seemingly in L5 and S1 dermatomal distribution.

242-243,245

12/04/YYYY KennethXXXXX,M.D., APC

Initial orthopedic surgical consultation report for right hand pain and lumbarspine soreness:Patient injured his right hand and suffered an open fracture of the right index fingermetacarpal in a MVA on 05/24/YYYY. In addition he suffered abrasions to the leftleg and fractured his left ankle. He had a lumbar spine strain. Patient states he wore acast or splint on the hand, followed by hand therapy. He did hand therapy for aboutfour months at Hollywood Hands. Surgical care and therapy were helpful.

*Reviewer’s comment: Therapy notes from XXXXXSurgical Care is unavailable forreview, hence the details about the patient’s right hand injury, its treatment andprognosis is unknown over a period of 4 months.

He has ongoing dysfunction of the right hand however and comes in today forassessment.

Right hand: He reports pain in the right hand and he points to the dorsal aspect ofthe index finger metacarpal on the radial side. There is a healed wound at this site.He states it is still painful where the skin was cut. He has occasional throbbing painat rest. He takes Naprosyn or Vicodin about one to two times per week for his handand other body pains. He reports decreased grip strength on the right side and pain in

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the dorsal aspect of the right hand if he strikes it against a surface. Cold weathermakes his symptoms worse.Lumbar spine: He reports ongoing soreness in his back. He is under the care of Dr.Obukhoff. He had back surgery on June 1, YYYY. Apparently he had a discectomy.

Physical examination:Cervical spine: He has mechanical stiffness of the cervical spine.Bilateral shoulders: He has full active range of motion of his shoulders. Rotatorcuff strength is 5/5.Bilateral elbows: There is slight right lateral epicondylitis with a slightly positiveCozens test.Right wrist and hand: He has well healed scars in the dorsal aspect of the righthand. There is an oblique scar that he states is from where the bone came through theskin. He has punctate scars more distally from where he states pins were placed intohis bone.

The MP joint arc of motion of the right index finger is -20-60° with instability of theradial collateral ligament at the MP joint. In flexion stress testing of the radialcollateral ligament has excessive instability when compared to the left side. The rightring finger metacarpal is dysmorphic from an old injury. In the right palm he ismarkedly tender at the metacarpal head region. There is crepitus without franklocking.

JAMAR Dynamometer III measurements:Right hand: 26/28/34Left hand: 40/48/45

Three views of the right hand show a healed oblique fracture to the right index fingermetacarpal neck. The fracture extends between the articular surface and the radialcondyle. There is dysmorphic appearance. There has been a slight malunion at thissite. Notably this anatomic alignment has not restored the proper collateral ligamentrelations.

*Reviewer’s comment: Right hand X-ray is unavailable for review.

Procedure: As a diagnostic and therapeutic maneuver, the right index finger flexortendon sheath was injected with local anesthetic mixed with corticosteroid. This gavehim good relief of the pain at this site.

Impression: Right index finger open metacarpal fracture status post open reduction and pin

fixation on May 26, YYYY. Right index finger persistent flexor tendon tenosynovitis status post injection on

December 4, YYYY. Right index finger metacarpophalangeal (MP) joint radial collateral ligament

laxity.


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Discussion: Patient suffered a fracture that went obliquely through the end of themetacarpal of the index finger. The collateral ligament attaches to the condyles of themetacarpal. There is a shift of the articular surface proximally and ulnarly and thenormal relationship of the collateral ligaments is somewhat off. This results in laxityof the MP joint in flexion and limits his total flexion of the MP joint.He is having pain on the flexor tendon sheath as well. I am not sure how muchtherefore I injected the flexor tendon sheath today as a diagnostic as well astherapeutic maneuver. In regards to the instability and malunion, there is nointervention at this time that is reasonable that would help him. An osteotomyalthough possibly effective, may make him worse. I do not recommend he pursue anosteotomy. Rather, I think he is stuck with the painful dysfunction he has of the righthand. He performs forceful activities. He notes when he performs very forceful workthe pain gets worse. This is consistent with the underlying pathology.In regards to the right lateral epicondylitis, at the moment this is minimal to slight. Ifthis gets worse in the future he should be able to return for medical care. His lumbarspine is under the care of Dr. Obukhoff. I defer lumbar spine care to Dr. Obukhoff.He will follow-up with me in six weeks to assess the results of today’s injection.

01/27/YYYY SergeXXXXX, M.D.

Referral report for MRI of lumbar spine

*Reviewer’s comment: MRI of lumbar spine is unavailable for review.

444

04/27/YYYY XXXXXMemorialHospital

SergeXXXXX, M.D.

History and physical for interbody fusion of L5-S1:Patient has continued low back pain, which is now worsened, and constant, 6-10/10,worse with prolonged action, with pain radiation to left side more than the right sidewith numbness. Here for surgery after change since contact with Dr. Obukhoff.

442-443


SergeXXXXX, M.D.

Operative report for transforaminal reexploration of previous laminectomy:Pre and post operative diagnosis: L5-S1 severe disc injury with back painsyndrome and radiculopathy.

Procedures performed: Transforaminal reexploration of previous laminectomy,facetectomy, diskectomy, decompression of nerve root followed by interbody fusionand posterolateral fusion utilizing pedicle screws and rods.

Indications for surgery: The patient previously underwent microdiscectomy for hislower back injury. It has given him some relatively good relief of pain syndrome onthe left side in the S1 dermatomal distribution although later on he started developingincreasing lower back pain and his pain started radiating down his leg again. He wasdiagnosed with reherniation and subsidence of disc and offered surgical treatmentand consented for surgery.

Findings: The patient was found to have a significant tear in annulus at theforaminal level and instability.

420-421


Inpatient internal medicine progress notes: Illegible notesStatus post L5-S1 anterior lumbar interbody fusion 04/27/YYYY, after reportedcomplications. Admitted to the hospital for post operative. Reports 6/10 aftermedication, positive for nausea and vomiting, ok on CLD and ambulation. Foley in

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SergeXXXXX, M.D.

place.

Assessment and plan: Status post lumbar fusion. POD #0, doing well. Postoperative pain 10/10-6/10 with medication but remains above acceptable threshold topatient. Add Dilaudid 1 mg for pain greater than 6. Nausea post operative, addZofran as needed. Advised diet as tolerated. IVF _____ taking significant fluids.Discharge foley and ambulate with assist in morning. Plan to use and escalate PMS.SCDS and is for DVT and plan prophylaxis. Discharge pending pain control, POtolerance ambulation.


Inpatient internal medicine progress notes:Positive for nausea no vomiting.Stop Foley/IVF

438


ShahriarXXXXX, M.D.

Inpatient internal medicine progress notes: Illegible notesPositive for nausea and vomiting.Gait: Getting _____ footUrine: Using catheter

Assessment and plan: Continue on pain management Continue off IVF Off Foley Advanced diet post operatively as tolerates Monitor for fever and leukocytosis Monitor for N/V, constipation and passing gas. Ambulate with PT/OT as

tolerates Monitor labs

435


ShahriarXXXXX, M.D.

Inpatient internal medicine progress notes:Assessment and plan: Stop foley when able to ambulate independently Stop Hemovac when drainage decreased Advance diet post operatively as tolerates Monitor for fever and leukocytosis Monitor for nausea/vomiting and passing gas Ambulate with PT/OT as tolerates Monitor labs for drop in Hematocrit and hemoglobin

436


Cy XXXXX,M.D.

Discharge summary for lower back pain and radiculopathy:Interval diagnosis: Lower back pain and radiculopathy L5-S1 severe diskInjury.

Procedure performed: L5-S1 posterior lumbar interbody fusion

Chief complaint: Lower back pain and numbness and tingling in lower extremities.

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Patient is a 38year old male with history of motorcycle accident leading to severelower extremity pain. He underwent a microdiscectomy for his lower back injury inYYYY. He had for a while pain relief on the left side of the S1 dermatomaldistribution but later on he started developing increased lower back pain withradiation down in his leg. On imaging the patient was found to have a significant tearin the annulus at the foraminal level and instability.

Hospital course: The patient was admitted on 04/27/YYYY and the next morningtaken to surgery. He had a transforaminal re exploration of previous laminectomyfacetectomy, discectomy decompression of nerve root, lumbar interbody fusion andposterolateral fusion utilizing pedicle screws and rods. The procedure wasuncomplicated Estimated blood loss was 50 ml. The patient’s pain was wellcontrolled postop on Norco. Within a few hours of surgery, the patient was toleratinga diet. Over the next 3 days the patient was medically optimized with pain controland physical therapy for ambulation and mobility. On discharge, the patient was ableto ambulate up to 900 feet with the help of a walker.

Discharge medication: Norco 10/325 mg 1 tablet for every 8 hours as needed forpain.

Discharge activities: As tolerated no bending, twisting or lifting.

Wound management: Keep surgical site dry.

Follow-up appointment: Dr. Obukhoff in 1 2 weeks.

Condition on discharge: Stable. The patient was afebrile with a temperature of 97.2,pulse 83, respiratory rate of 20, blood pressure 16/69, pain scale 5/10 on lower backsurgical site. The patient was alert and oriented, functionally independent, able toperform ADLs and was ambulating with the help of a walker.

Discharge plan: Discussed in detail with the patient and the family.

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