Observation Of Mr. Baird

Mr. Baird resides in a three bedroom home with his wife and two small dogs. He replied, his son had built the house. There are three bedrooms, two were upstairs and the master with a bath on the first floor. The house had an attached garage and a back deck with railings. We sat at the dining table and he was receptive to my involvement. I observed Mr. Baird walking throughout the house without using a mobility devices i.e. cane and walker, which I observed were sitting in the living room. Mr. Baird recalled the accident and stated he was rear ended 2008. He had two days of discomfort and on the third day he was seen by Dr. Munk, Orthopedic spine who eventually did a fusion on his lumbar spine. Mr. Baird had the procedure done at St. John South Macomb
Hospital in Warren, Michigan and was hospitalized for two weeks.
Mr. Baird replied, he has pain to his lumbar back with pain radiating into his right leg. The pain awakens him from sleep Mr. Baird usually obtains 4 hours of sleep and is up at 6:00 am. Mr. Baird rates his lumbar discomfort a “9” on the 1-10 pain scale. Mr. Baird described his foot being numb and tingling sensations. The discomfort can be stabbing. He had two epidural injections at Beaumont Hospital Pain Management but had not received the third injection until recently on August 4, 2017. Mr. Baird felt the first two had provided some relief but not complete pain removal. He does wear a back support brace. I inquired about how many hours he uses his brace for and he replied, all the time. I suggested he remove the brace when he is sitting or lying down. I inquired about the recent falls he had experienced and the location of the falls. Mr. Baird replied he was outside walking to the corner (He has a corner lot) and his leg gave out. When this occurred he fell, even when he used his
walker. He report he had fallen three days before the July 7 evaluation. I inquired on the location, again he replied, I was walking outside towards the corner and fell on the same side that I fell on the last time, which is my right side. I inquired if he had worn his brace and he replied “no”. I inquired if it was a foot brace as some individual who had peroneal nerve damage have had foot drop as they can’t lift there leg up when walking. Mr. Baird denied this type of brace. I asked to see the brace but he couldn’t locate it. I inquired why he had not worn his brace and Mr. Baird replied that it cuts into his skin. I discussed that there is a potential that it could be modified and he should go back to the location that supplied it to him. Mr. Baird had an abrasion to his right low leg and different stages of bruising.