Notes that claimant presented with low back pain that radiates down his legs bilaterally as distal to his toes. Pain at a 9, difficulty standing/sitting, pushing, squatting, kneeling, and twisting.
By 11/30/10, claimant had " reached point of maximum recovery. He is now permanent and stationary and has residual permanent disability.
Objective evidence of disability: MVA resulted in strains/sprains to the lumbar as well as a r. forminal disc herniation of the L3-4 disc with impingement on the right L3 nerve root. Minimal right sided protrusion of the L5-S1 disc just abutting the right S1 nerve root. Throughout tx course, he continually displayed decreased range of motion and positive orthopedic testing indicating lumbar disc dysfunction with radicular symptomatology.
On Physical Exam: paravertebral musculature tenderness from the level of C5-C6 L5-S1 bilaterally. Spasms, and paresthesia down each leg, positive Kemps and straight leg raise.
Impression: R. foraminal disc herniation of the L3-L4 disc with impinment on the right L3 nerve root.
Needs to rest in addition to the allotted breaks.
Knee Pain began in June of 2011
1) Marked patellofemoral chondromalacia, etc...
Significant loss of the medial joint compartment, articular cartilage in the medial femur and femoral condyle. Some arthritic changes also in the patellofemoral joint and suspected severe arthritis of the joint.
At Delaware Valley Orthopedic and Spine Surgicenter
Debridement and lavage of the right knee + Therapeutic injection
Arthritis largely resolved clinically on adalimumab
Inflammatory arthritis of the knee
Slit his wrist and 302's by gf.
Dx Depression, NOS, GAF 30
Started on Paxil, felt better. GAF 65 on discharge