Sample Case Study: A Case Summary Of A Patient

DOI: 6/15/2010. The patient is a 50-year-old female sewer/engineering technician who sustained repetitive trauma to her eyes, hands, waist, back, right hip, right leg and forearm. Panel QME Dr. Morris, IW is P & S on 0/08/14 with 19 % permanent disability. Future e medical care incldues
MRI of the lumbar spine on 11/20/12 shows a 1.0 mm broad-based posterior disc bulge at L3-4. There is also a 2.5 mm broad-based posterior disc at L4-5 that caused indentation of the anterior thecal sac. At L5-S1 level, there is hypertrophy of the bilateral facet joints, causing mild bilateral foraminal narrowing.
According to the agreed panel QME report on 5/28/14, analgesic and anti-inflammatory medications should be made available to the patient, but otherwise no additional care is indicated as the patient states that none of the treatment that she has received over the past years has helped her and in fact she states that her condition has actually worsened. The examiner notes that any additional physical medicine treatment is not going to be helpful. Patient was deemed P & S on 02/2011.

Based on the progress report dated 09/07/16 by Dr. Morris, the patient rates her pain as 7/10 at average with medications and 8/10 without medications. She has pain in the lumbar spine with radiation to the feet, left greater than right. She has functional benefits of medication. Response to therapy is unchanged from prior