Medical Chronology

Jonathan XXXX

File No.:

MEDICAL CHRONOLOGY

Jonathan XXXX

DOB: 01/29/YYYY

Date of Service / Provider / Document / Treatment Summary / Fees / PDF Ref /
07/08/YYYY / ABCD XYZ Hospitals
J. Edsel XXXX, M.D. / X-ray of thoracic spine / Indication: Back pain
Conclusion: Negative thoracic spine / $137.16 / 100
07/08/YYYY / ABCD XYZ Hospitals
J. Edsel XXXX, M.D. / X-ray of lumbar spine / Indication: Back pain
Conclusion: Negative lumbar spine / $137.16 / 101
07/08/YYYY / ABCD XYZ Hospitals
Linda Marie XXXX, FNP
Paul Richard XXXX, M.D. / ED provider note / Chief Complaint: Fast Track-Motor Vehicle Crash
Time seen by MD 1957 hrs
Exam limitations: No limitations
Patient who presented to ED with pain mid to lower back. Patient states he was involved in 2 accidents today. This morning he was a restrained driver and was stopped and hit in rear. Second accident occurred later in morning. Patient was a restrained front seat passenger and truck was hit on driver side. Occurred this morning. Severity moderate injury/pain.
Location: Back
Context: Driver, passenger, restraints, ambulatory at scene, vehicle impacted
Modifying factors: Worse with: movement.
Loss of consciousness: No loss of consciousness
Associated symptoms: Muscle spasms
Trauma review of systems: Unable to obtain
Medical decision making: Patient involved in 2 MVA’s with worse back pain today. Advised to Rest. Ice packs and warm compresses. Follow up with PMD or XXXXX Ortho if no improvement.
Clinical impression: Acute mid and lower back strain status post MVC.
Disposition: Discharge to home or self care.
Prescriptions: Vicodin 5/500 1-2 tablet per oral every 4-6 hour as needed for pain.
Flexeril 10 mg #21 1 tablet per oral thrice a day as needed for muscle spasm. May return to work on 07/11/YYYY
*Reviewer’s comments: The ER visit at XYZ ER services, LLC is charged at $596.00 (PDF REF: 129). We have captured the charge amount billed at $676.95 under ABCD XYZ Hospitals. The bills for medication dispense has also been added. / $676.95 / 95-99, 102, 154
07/11/YYYY / ASDF Family YYYY / Work status report / Patient has been under my care from 07/11/YYYY to 07/15/YYYY and is able to return to work on 07/18/YYYY. / $67.00 / 11
08/08/YYYY / XYZA Medical Center
Duncan F XXXX, DPT / Initial physical therapy evaluation for low back pain / Diagnosis: Whiplash injury, MVC.
The patient reports he was hit from behind by a truck in the 1st accident. He subsequently went home to his wife and then he and his wife were going to the hospital. He was hit on the side of his car a 2nd time. The patient reports pain level can go up to a 7/10. The patient works in the welding field. The patient reports he hurts in the mid thoracic and lumbar region, 2 different spots. The patient is on a leave of absence from work at this time.
Pain scale: Rated 7/10 intermittently.
Palpation; Increased tenderness at T6 and T8 vertebral levels, mid thoracic and bilateral lumbar.
Range of motion: Current range of motion within functional limits. Increased discomfort at end range on trunk extension, trunk flexion. Follows right-sided body pattern restriction. Left lateral trunk flexion restricted greater than right lateral trunk flexion. Restricted right hip extension greater than left hip extension. Restricted right hip external rotation greater than left hip external rotation. Restricted right hip abduction greater than left hip abduction.
Posture: Forward head posture. Follows right-hand dominant body pattern, low right shoulder, high right hip, longer left lower extremity, shorter right lower extremity secondary to hip imbalance as above.
Special tests: Positive straight leg raise left. Positive functional leg length discrepancy secondary to hip imbalance. Right hip higher than left hip.
Assessment: The patient presented to our clinic today with mid thoracic, low back pain. The patient would benefit from physical therapy to address deficits listed above.
Treatment: Treatment included therapeutic exercise as follows:
·  Right swimsuit poses 3 x30 seconds.
·  Right clam 1 x25.
·  Right hip flexor stretches 3 x 10 seconds.
·  Right latissimus dorsi stretch 3 x10 seconds.
·  Right shoulder external rotation 2 x 15, orange T-band.
The patient was instructed in the home exercise program and demonstrated good technique and understanding by the end of treatment.
Plan of care: Patient to attend x2/week x4 weeks. Treatment will include therapeutic exercise, modalities, and manual massage therapy. Plan of care has been discussed with the patient and he is in agreement with the treatment plan. / $373.00 / 42-44
08/16/YYYY-08/18/YYYY / XYZA Medical Center / Summary of multiple physical therapy visits for low back pain / Total number of visits: 2
Areas treated: Low back region
Outcome as on 08/18/YYYY: Patient reports increased pain with exercises.
*Reviewer’s comment: Multiple physical therapy visits have been combined and provided as a summary / $756.00 / 52
08/22/YYYY / XYZA Medical Center / Final physical therapy evaluation for low back pain / Duncan asked this therapist to discontinue ball exercises at this time secondary to increased pain.
Assessment: Discontinue use of ball today. / $378.00 / 79
11/15/YYYY / ABCDE Orthopaedics
Whitney XXXXX, PA
Robert M XXXXX Jr. M.D. / Visit for low back pain / Lower back:
Severity: Pain level 2-6/10
Duration: Date of onset: (7/084011. 2MVA In same day)
Context: MVA
Alleviating factors: Nothing helps
Aggravating Factors: Lifting: carrying; bending/squatting; getting out of bed, going from sit to stand
Associated Symptoms: Swelling; warmth; instability
Previous PT: Did not help
Working: No
Patient presents with complaint of low back pain. He did have a radiating pain across his back and do both legs with the Impact.
The patient works as a welder and was out of work. He did go to physical therapy for 4-5 visits at length hospital. He got some mild relief and tried returning to work. Upon returning to work his beck pain intensified causing him to leave work.
Physical exam:
Lumbar spine: Tenderness over the region at L5. Pain only with forward flexion and extension over the SI region.
Range of motion:
Left rotation: 20 degrees
Right rotation: 20 degrees
Left lateral flexion: 25 degrees
Right lateral flexion: 25 degrees
Flexion: 60 degrees
Extension: 20 degrees
Assessment and plan:
Sciatica – X-ray of lumbar spine.
Since the patient has been to supervised physical therapy and Since he has also gotten minimal relief from anti-Inflammatory and pain medications well proceed with an MRI of the lumbar spine for further evaluation. The patient will continue stretching and doing exercises on his own at home. He will remain out of work at this point in time.
Parafon Forte was given as a muscle relaxer since he is tried Flexeril and the some with no relief. He has Oxycodone on hand as needed.
*Reviewer’s comment: X-ray of lumbar spine is billed at $136.00. The X-ray report is not available. / $378.00 / 32-34
11/25/YYYY / ABCD XYZ Hospitals
Wiley Phillips XXXXX, M.D. / ER visit for low back pain and earache / Chief complaint: Headache
Stated complaint: Migraine and toothache
Patient presents today with complaint of low back pain and earache. Patient states he has run out of his Percocet and Dr. is unable to see him. Patient also do right sided earache. Patient has history of otitis in this ear with hearing loss.
Physical exam:
ENT: Abnormal TM right (erythema and scarring)
Medical decision making: Course is uneventful; patient is given 1 Percocet.
Impression: Right otitis media and chronic back pain
Prescriptions: Percocet 8 tablets and Amoxicillin. / $678.83 / 91-94, 135, 139
02/09/YYYY / ABCDE Orthopaedics
Matthew J XXXXX, M.D. / MRI of lumbar spine / Indication: Low back pain
Impression: Mild degenerative disc disease of the lumbar spine, most pronounced at L4-L5 with a slight left-sided predominance. / $597.00 / 30-31
02/20/YYYY / ABCDE Orthopaedics
Robert M XXXXX Jr. M.D. / Follow-up visit for sciatica / Pain: 4/10
Alleviating factor: Rest
Review of systems: Reports muscle aches, muscle weakness and back pain
Physical exam: Pain only with forward flexion and extension over the SI region.
Assessment and plan: Sciatica
MRI does correlate with the patient’s left-sided leg and low back pain.
Alter discussing the MRI with the patient and his wife in finding out that the patient has a severe inversion to injections/needles they were given the options of possible Lumbar Epidural Steroidal Injection (LESI) Injections or going to meet Dr. Xxxx for possible surgical consideration. Being that there Is no 100% guarantee that the injections would be beneficial they like to be seen by Dr. Xxxx. Medications were provided today and reassessment will be on an as-needed.
Prescriptions:
Lortab 7.5 mg – 500 mg
Parafon Forte DSC 500 mg tablet / $99.00 / 27-29
07/11/YYYY / XYZA Family YYYY Northeast
David XXXXX, M.D. / Follow-up visit for back pain / Patient with back pain. He has got left-sided radicular symptoms and was sent for orthopedic consult and they recommended injections, but given the fact that they said the outcomes were not that good he went and saw an orthopedic back surgeon, who would not operate until he had a lawyer and then decided not to operate because of the lawyer involved. Long story short, the pain has persisted for the last year, it has kept him to of work. He has been on multiple agents to include Vicodin, OxyContin, Soma, etc. Nothing really works well. If he rests completely he is without pain, but if he gets up and does anything, even mildly strenuous, pain starts right back in like it were day.
Objective exam:
Back: Tenderness to palpation in the left lumbosacral paraspinous muscles. Equivocal straight leg lifts on the left.
Assessment: Lumbar radiculopathy.
Plan: I am going to get the MRI report from Midland’s Orthopaedics and if the report shows an operable lesion, I am going to get him in to see Dr. ______Neurosurgical. Otherwise, consider Dr. XXXXXX. / $170.00 / 24
08/16/YYYY / ABC Lake Family YYYY
Tamera D XXXXX, M.D. / Office visit for chronic back pain / Patient has been having chronic back pain for the past one year since being involved in two motor vehicle accidents on 07/08/YYYY. His previous PCP, Dr. XXXXX has been giving him Flexeril and Percocet as needed. He has completed three to four rounds of physical therapy, which actually made the pain worse. He was fired from his job at that point and lost his insurance. They did, however, see a back surgeon at ABCDE, who would not operate on him without insurance. He has never seen pain management because he has not been interested in it. He has good and bad days. He did see a neurologist with a negative exam. He states that he has been out of his medications for the past two days.
Assessment and plan:
·  Low back pain: We will refill his Flexeril 10mg to be used up to three times a day and l did give him Oxycodone 5 mg to be used p.r.n. #60 with zero refills. We will get him in to see Dr. XXXXX as soon as possible and put in a referral to XXXXX Orthopaedics as well per the patient request.
·  Allergic rhinitis: He will continue the Allegra and I gave him the samples of Nasonex to try two sprays in each nostril once a day. / $50.00 / 175
08/22/YYYY / ABC Lake Family YYYY
Stephen M XXXXX, M.D. / Follow-up visit for low back pain / The patient now has increased pain whenever he increases activities, especially the day after the activity. Occasionally, he will get sharp periods of numbness in the left leg. He rates his pain from 2 to 9 on the numeric rating scale.
Physical examination:
Positive findings include tenderness at L4-L5 on the left, L5-S 1 bilaterally with vibratory sensitivity in the left lower lumbar paraspinals.
Assessment: Lumbar spondylosis with radiculopathy, trigger points and muscle spasm.
Plan: The patient will be treated conservatively initially. He was shown exercises to mobilize the lumbar spine. He was given Cyclobenzaprine for sleep at night Voltaren gel for topical application. He will also take Aleve twice a day and use ice for his paraspinal muscle spasm. He will return for a followup in two weeks, if the pain is not improved, lumbar injections will be done at that time. / $174.25 / 174
07/11/YYYY-03/25/YYYY / ASDF Family YYYY / Established patient level 3 and 4 / Medical Bills / $813.00 / 7-9
04/08/YYYY / XYZA Medical Center
Joshua W XXXXX, M.D. / MRI of lumbar spine / Clinical data: Back pain with lower extremity radicular symptoms.
Impression: Very mild degenerative disc disease at L4-5 and L5-S1 with minimal broad-based disc bulges with likely some very mild left exiting nerve root contact at the L4-5 level. / $3,926.00 / 45-46
05/01/YYYY / XXXXX Orthopaedics
William T XXXXX, M.D. / Office visit for low back pain / Patient is here for second opinion. Seen and evaluated previously. Referred here by Dr. Michelle XXXXX. Pain worse with exercise, sitting, standing, walking, bending forward/backwards. Pain reduced when lying down and sitting. He apparently has had a variety of different opinions regarding his back and told for the most part they did not see anything changed in his back.
As far as his Oswestry scale, Oswestry scale is 34. Again, two years ago he was squashed up against a wall of a car and was headed on his way to his doctor to be evaluated after the first accident, got into a second accident. He has had a variety of anti-inflammatories, PT and various pain managements. He has had chronic pain management at this point. Apparently saw a variety of other physicians as well.
Physical exam:
Babinski’s is downgoing. Patient does not appear to have any gross clinical evidence of lag on flexion/extension. He only flexes about 30, extends 10-20 degrees, but he is noting when he first comes in the room to be squatting against the wall and can come out of a squat against the wall and bring his trunk to a vertical position without difficulty. He does this without the use of his hands or any furniture or bracing. He complains primarily of lower back, left side, up and down his back. Seems to have normal mechanics, though he has a very limited flexion/extension to exam which is not consistent with motion and function as we see on review and watch him in the exam room today.
Radiographs: As far as his lumbar spine, good disc height throughout the lumbar spine. Patient does not appear to have any lysis, listhesis or instability. SI joints look satisfactory. His hips look fine. Oblique views do not seem to show significant tumor, infection, cancer and/or lesion. Upright versus supine view looks fine. This is consistent with his MRI which shows little or no findings.
*Reviewer’s comment: X-ray of lumbar spine is unavailable for review
Plan: Clinically at this point, I do not see any evidence in this gentleman of any type of acute structural changes to his back. Both his neurologic, sensory and motor examination is unremarkable. He does complain of pain diffusely over his back, but both his MRI and plain X-rays do not suggest significant structural lesion. It is now two years since his last vehicular episode. I do not feel at this point that there is much from an orthopedic standpoint I can recommend to him. He has had chronic pain management. He has had a variety of PT and various other activities. Unfortunately two years out from the accident whatever subjective clinical complaints are present will probably continue. At this point, other than subjective clinical complaints, I do not see any obvious objective anatomic structural evidence of an injury. To the best of my orthopedic opinion, I feel at this point his spine is stable, functional and should be able to withstand the activities of daily living.
I did not recommend any care plan for him at this point. He clearly has seen a variety of physicians in the past. They have tried just about every other issue for him. As far as chronic musculoskeletal symptoms, some people do benefit from anti-inflammatories. I do not feel at this point long-term opiate use is useful and generally a year or two out, it is unlikely that physical therapy will change the natural history of subjective clinical complaints. / $527.00 / 118-120

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