Orthopedics Study

CHART NOTE

This patient states that he was seen at this pain clinic and was given a lumbar epidural injection 1 week ago.

The patient states that he has not noticed any significant help.

He has again been informed that an implant stimulator was recommended, but the patient does not want this device implanted.

The patient at this time is remaining on medication.

He will return here in 3 weeks.  He is going to pain clinic again for further assessment.

CHART NOTE

The evaluation on the above date indicated that the patient had a history of a lumbosacral sprain, and the clinical assessment and objective findings for the lower back examination did not reveal a neurological or musculoskeletal deficit.  At that time I suggested a CT scan to further correlate with the findings.

I did receive a CT scan of the lumbar spine.  The scan was from L3 to S1 and revealed a normal CT scan of the lumbar spine.  Patient also had an electromyogram performed, which was a normal study.

In view of the clinical objective findings, which indicated no neurological musculoskeletal deficit and excellent function and range of motion of lower back and lower extremity, and in conjunction with the normal CT scan and electromyogram, the patient exhibited no findings which would indicate a permanent or partial permanent disability, and based upon the previous studies, the patient should be able to perform in his usual and customary duties.

FOOTNOTE

Line 30.  Alternative:  L-3 to S-1.