Sample Medical Report
CLINICAL SUMMARY:
DOI: 5/31/2016. The patient is a 41-year-old male senior technician who sustained a work-related injury while working with high-pressure drilling equipment, he was struck in the leg with piece of metal from high-pressure hydraulic hose.
Patient is status post left lower extremity lateral subcutaneous fasciotomy, excisional debridement and washout on 05/31/16.
CT scan of the cervical spine dated 06/29/2016 showed mild degenerative changes at C5-6 level.
Per the medical report dated 07/11/16, the patient complains of cervical spine pain radiating to the bilateral upper extremities and low back and leg pain which radiates to the bilateral buttocks and hips. He has completed a formal course of physical therapy primarily for his left lower extremity, but not much was done for the cervical and lumbar spine. The patient sustained a left peritibial plane injury and underwent surgery. He complains of persistent lower back pain that radiates into the lower extremities bilaterally, greater on the left.
MRI of the lumbar spine obtained on 07/27/16 showed Grade 1 degenerative L3 retrolisthesis. No spondylolysis is seen. There is a disc degeneration, disc narrowing, disc pathology, annular fissure, endplate spondylosis, Modic 2 endplate change and facet arthrosis are present. Findings
DOI: 5/31/2016. The patient is a 41-year-old male senior technician who sustained a work-related injury while working with high-pressure drilling equipment, he was struck in the leg with piece of metal from high-pressure hydraulic hose.
Patient is status post left lower extremity lateral subcutaneous fasciotomy, excisional debridement and washout on 05/31/16.
CT scan of the cervical spine dated 06/29/2016 showed mild degenerative changes at C5-6 level.
Per the medical report dated 07/11/16, the patient complains of cervical spine pain radiating to the bilateral upper extremities and low back and leg pain which radiates to the bilateral buttocks and hips. He has completed a formal course of physical therapy primarily for his left lower extremity, but not much was done for the cervical and lumbar spine. The patient sustained a left peritibial plane injury and underwent surgery. He complains of persistent lower back pain that radiates into the lower extremities bilaterally, greater on the left.
MRI of the lumbar spine obtained on 07/27/16 showed Grade 1 degenerative L3 retrolisthesis. No spondylolysis is seen. There is a disc degeneration, disc narrowing, disc pathology, annular fissure, endplate spondylosis, Modic 2 endplate change and facet arthrosis are present. Findings