Mild degenerative disc disease with endplate osteophytosis
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.
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
Opines that she would require 2 hours of lying down for her back, can only occasionally lift 1-5lbs, rare/no stooping.
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.
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