Tina H.

Main

Accident

2/22/11

Rear ended

Jurisdictional

AOD

2/22/11

PFD

7/21/11

Objective

Radiographs of Thoracic Spine

2/24/11

Mild degenerative disc disease with endplate osteophytosis

Radiographs of the Lumbar Spine

2/24/11

Transitional L5 vertebral body with pseudoarthrosis formation on the right side; Degenerative disc disease at L5-S1 with gas present within the disc; Facet joint osteoarthritis at L4-5 and L5-S1, more pronounced on the right side.

MRI of Lumbar Spine

2/7/12

Lowest disc space is numbered as S 1/2
Narrowing of L5/S1 disc space with desiccation and left side hemilaminectomy defect with a disc bulge on the left.
Shallow disc bulge of L3/4

Opinion

Michael Goldstein, D.C.

4/2/12

Opines that she would require 2 hours of lying down for her back, can only occasionally lift 1-5lbs, rare/no stooping.

Treatment

Michael Goldstein (Chiropractor)

2/22/11 - 4/4/12

Debra Cullen- Worknet Exam

2/23/11

On examination: normal neuro exam, normal gait and transfer on and off table; Some mild muscle spasms aprreciated at the trapezium.

Pretty normal with the exception of some spasms. Assessment is: Cervical Strain/Sprain; Thoracolumbar Sprain/Strain

Claimant was temporarily taken out of work.

Worknet Occupational Medicine

2/23/11 - 2/24/11

John Park, M.D. (Greater Phil. Spine & Pain)

10/5/11 - 2/28/12

Injection

10/19/11

Injection

11/30/11

Goldstein

3/5/12

Most recent progress note from chiropractor:

moderate pain/stiffness on r. side of neck (5/10); moderate pain/stiffness in mid back (4/10); moderate pain/stiffness in lower back with pain radiating down the back of both hips and legs (6/10).

Taking Flexeril, Naprosyn, and Percocet daily to alleviate pain. Experiencing sleep difficulty.

Physical Exam: Noted tenderness from cervical through lumbar spine; decreased range of motion throughout; positive for multiple orthopeadic tests.

Assessment: See page