R. Barr

Main

MVA

5/5/10

Spine

Discharge Report: Progressive Rehab (Cupuano)

6/16/10 - 11/30/10

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.

Treated with Dr. Levinstein (Pain Managment)

7/27/10 - 3/19/13

Epidural into Spine (Dr. Mahoney)

7/28/10 - 7/29/10

MRI Lumbar Spine

9/30/10 - 10/1/10

Impression: R. foraminal disc herniation of the L3-L4 disc with impinment on the right L3 nerve root.

Oxycodone

11/30/10 - 12/1/10

Consult on shots vs surgery (Levenstein)

7/5/11 - 7/6/11

Opinion Evidence

Dr. Levinstein MSS

12/6/2012 - 12/7/12

Needs to rest in addition to the allotted breaks.

R. Knee

Knee pain began

6/1/2011 - 6/2/2011

Knee Pain began in June of 2011

Knee Surgery (Aria Health)

7/29/11 - 7/30/11

MRI of R. Knee

2/3/12 - 2/4/12

1) Marked patellofemoral chondromalacia, etc...

Dr. Okin (DVOSC)

2/13/12 - 2/14/12

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.

Knee surgery

3/2/12 - 3/3/12

At Delaware Valley Orthopedic and Spine Surgicenter

Debridement and lavage of the right knee + Therapeutic injection

Treated with Dr. Cohen at Temple U., Rheum

5/15/12 - 2/1/13

Large R. Knee Effusion (Drained)

6/29/12 - 6/30/12

Dr. Cohen: Impression (Resolved)

12/16/12 - 12/17/12

Arthritis largely resolved clinically on adalimumab

Dr. Cohen: Impressio

2/1/13 - 2/2/13

Inflammatory arthritis of the knee

L. Hip

Mental Health

302- Suicide attempt

3/3/2008 - 3/7/2008

Slit his wrist and 302's by gf.

Dx Depression, NOS, GAF 30

Started on Paxil, felt better. GAF 65 on discharge