Neurology Case Studies

Dear Attorney,

I have been taking care of the above-mentioned patient because of a back injury he received in a rear-end automobile accident.  After this accident, he had increased pain in his back and, in addition, had left leg pain for the first time.  He previously had back pain but never leg pain before.  A CT scan showed a herniated disk at L4-L5 with compression of the nerve root on the right side.  He also had a bone scan which was normal.

During my exam he had trouble raising up on his left side.  There was pain in the lumbar spine and pain in the posterior aspect of the left leg and calf.  Reflexes were intact.  There was weakness in the left foot consistent with a herniated L4-L5 disk.  He was placed on strict bed rest and given a prescription for Vicodin, and was seen again 1 week later.  At that time he was slightly better.  He was to maintain rest, and he was only advised to be working no more than 2 or 3 hours a day.  He was seen again
1 week later.  He was still in a lot of pain but slowly improving.  He was advised to avoid sitting for long periods of time.

In summary, this patient has a herniated L4-L5 disk on the left side.  I would consider that the injury was an aggravation of a preexisting back condition.  He has definite weakness of the foot.  The outlook is guarded at this time.  It is certainly possible that he may need a disk excision if the pain worsens.  I would consider him still partially disabled.  I cannot tell at this point how long this will last, but it certainly could be several more months or longer depending on his clinical course.  I will keep you updated as to his progress as I see him in the office.

If you have any further questions about his medical evaluation, please feel free to call on me.

Sincerely yours,

Name.

FOOTNOTE

Line 13 (Page 1).  Re was not dictated but was added to demonstrate proper letter format.

Line 23 (Page 1).  In addition is redundant when used with also, and it was deleted.

Lines 22, 28, 37, 41 (Page 1).  Alternative:  Disc.