Case overview
See the medical history in context.
MediScan’s case overview brings automatically extracted patient details together with a narrative case summary. Injury history, treatment, employment, and social history provide context, with supporting documents listed in Source Files & Records.
Garcia, M.
Details| Name | M. Garcia |
|---|---|
| Injury Description | Workplace lift of a carton at County Logistics on 03/12/2024, with immediate low-back pain aggravating a prior 2018 lumbar strain. Ongoing lumbar symptoms with L4-L5 disc displacement on MRI; activity-limited pain with bending, lifting, and prolonged standing; and modified duty with a 25 lb lifting restriction. Symptoms include stiffness, limited lumbar flexion, difficulty with warehouse stacking and shift standing, and activity-limited work capacity. Subsequent orthopedic consultation, physical therapy, occupational therapy, and ongoing PTP management for lumbar strain and disc displacement. No lumbar surgery is documented. |
| Date Of Injury | 03/12/2024 |
| Insurance | Pacific Compensation |
| Employer | County Logistics |
| Occupation | Warehouse Associate / Material Handler |
| DOB | 06/08/1987 |
| Claim Number | WCC-24-4419 |
| Adj Number | ADJ0004419 |
Summary
M. Garcia
History of Injury
The patient's pre-injury records document low-back treatment in 2018, including lumbar strain and a course of physical therapy, with no lumbar surgery noted. No other prior lumbar procedures are documented in the available records. On 03/12/2024, while employed as a warehouse associate at County Logistics, the patient reported immediate low-back pain after lifting a carton at work. Pain increased with flexion. The patient presented the same day to County General, where the visit documents lumbar strain. The patient was released with NSAID, ice, and outpatient follow-up, and was taken off work pending PTP evaluation.
History of Treatment
On 03/14/2024, Chen, M.D., at Westside Occupational evaluated the industrial lift and persistent lumbar symptoms. The diagnosis was lumbar strain. Modified duty was started with a 25 lb lifting limit and no repetitive bending, and a physical therapy referral was made. Lumbar radiographs on 03/15/2024 showed no acute osseous abnormality. Physical therapy began 03/22/2024 at Restore PT. Notes document lumbar stiffness and pain with prolonged standing and a plan for core stabilization. A handwritten flow sheet dated 03/29/2024 is flagged illegible, and the summary of that page may be impacted. Lumbar MRI on 04/02/2024 at Pacific Imaging, interpreted by Okada, L., M.D., demonstrates L4-L5 disc displacement. Remaining lumbar levels are described as unremarkable. Laboratory testing on 04/19/2024 showed an elevated WBC with remaining values within reference range. A ketorolac injection was administered on 04/26/2024. Orthopedic consultation on 05/08/2024 with Walsh, S., M.D., reviewed the MRI, continued modified duty and therapy, and did not recommend surgery. Physical therapy was discharged to a home program in July 2024. The most recent PTP note continues modified duty with a 25 lb lifting limit.
Employment History / Job Description
The patient works as a warehouse associate / material handler at County Logistics. Job duties documented in the PTP report include lifting, stacking, and prolonged standing during a shift. Modified duty has continued with a 25 lb lifting limit and no repetitive bending. The deposition excerpt describes the lift at County Logistics and ongoing limits with bending and standing.
Social History
Tobacco and alcohol use are denied in the available records. No regular exercise program is documented. Living situation is not further detailed in the uploaded records.
Source Files & RecordsGarcia_records_FINAL(7)
MRI_lumbar_Garcia(1)
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Garcia, M.
Details| Name | M. Garcia |
|---|---|
| Injury Description | Workplace lift of a carton at County Logistics on 03/12/2024, with immediate low-back pain aggravating a prior 2018 lumbar strain. Ongoing lumbar symptoms with L4-L5 disc displacement on MRI; activity-limited pain with bending, lifting, and prolonged standing; and modified duty with a 25 lb lifting restriction. Symptoms include stiffness, limited lumbar flexion, difficulty with warehouse stacking and shift standing, and activity-limited work capacity. Subsequent orthopedic consultation, physical therapy, occupational therapy, and ongoing PTP management for lumbar strain and disc displacement. No lumbar surgery is documented. |
| Date Of Injury | 03/12/2024 |
| Insurance | Pacific Compensation |
| Employer | County Logistics |
| Occupation | Warehouse Associate / Material Handler |
| DOB | 06/08/1987 |
| Claim Number | WCC-24-4419 |
| Adj Number | ADJ0004419 |
SummaryM. GarciaHistory of Injury
The patient's pre-injury records document low-back treatment in 2018, including lumbar strain and a course of physical therapy, with no lumbar surgery noted. No other prior lumbar procedures are documented in the available records. On 03/12/2024, while employed as a warehouse associate at County Logistics, the patient reported immediate low-back pain after lifting a carton at work. Pain increased with flexion. The patient presented the same day to County General, where the visit documents lumbar strain. The patient was released with NSAID, ice, and outpatient follow-up, and was taken off work pending PTP evaluation.
History of Treatment
On 03/14/2024, Chen, M.D., at Westside Occupational evaluated the industrial lift and persistent lumbar symptoms. The diagnosis was lumbar strain. Modified duty was started with a 25 lb lifting limit and no repetitive bending, and a physical therapy referral was made. Lumbar radiographs on 03/15/2024 showed no acute osseous abnormality. Physical therapy began 03/22/2024 at Restore PT. Notes document lumbar stiffness and pain with prolonged standing and a plan for core stabilization. A handwritten flow sheet dated 03/29/2024 is flagged illegible, and the summary of that page may be impacted. Lumbar MRI on 04/02/2024 at Pacific Imaging, interpreted by Okada, L., M.D., demonstrates L4-L5 disc displacement. Remaining lumbar levels are described as unremarkable. Laboratory testing on 04/19/2024 showed an elevated WBC with remaining values within reference range. A ketorolac injection was administered on 04/26/2024. Orthopedic consultation on 05/08/2024 with Walsh, S., M.D., reviewed the MRI, continued modified duty and therapy, and did not recommend surgery. Physical therapy was discharged to a home program in July 2024. The most recent PTP note continues modified duty with a 25 lb lifting limit.
Employment History / Job Description
The patient works as a warehouse associate / material handler at County Logistics. Job duties documented in the PTP report include lifting, stacking, and prolonged standing during a shift. Modified duty has continued with a 25 lb lifting limit and no repetitive bending. The deposition excerpt describes the lift at County Logistics and ongoing limits with bending and standing.
Social History
Tobacco and alcohol use are denied in the available records. No regular exercise program is documented. Living situation is not further detailed in the uploaded records.
Source Files & RecordsGarcia_records_FINAL(7)
MRI_lumbar_Garcia(1)
Garcia, M.
Details| Name | M. Garcia |
|---|---|
| Injury Description | Workplace lift of a carton at County Logistics on 03/12/2024, with immediate low-back pain aggravating a prior 2018 lumbar strain. Ongoing lumbar symptoms with L4-L5 disc displacement on MRI; activity-limited pain with bending, lifting, and prolonged standing; and modified duty with a 25 lb lifting restriction. Symptoms include stiffness, limited lumbar flexion, difficulty with warehouse stacking and shift standing, and activity-limited work capacity. Subsequent orthopedic consultation, physical therapy, occupational therapy, and ongoing PTP management for lumbar strain and disc displacement. No lumbar surgery is documented. |
| Date Of Injury | 03/12/2024 |
| Insurance | Pacific Compensation |
| Employer | County Logistics |
| Occupation | Warehouse Associate / Material Handler |
| DOB | 06/08/1987 |
| Claim Number | WCC-24-4419 |
| Adj Number | ADJ0004419 |
SummaryM. GarciaHistory of Injury
The patient's pre-injury records document low-back treatment in 2018, including lumbar strain and a course of physical therapy, with no lumbar surgery noted. No other prior lumbar procedures are documented in the available records. On 03/12/2024, while employed as a warehouse associate at County Logistics, the patient reported immediate low-back pain after lifting a carton at work. Pain increased with flexion. The patient presented the same day to County General, where the visit documents lumbar strain. The patient was released with NSAID, ice, and outpatient follow-up, and was taken off work pending PTP evaluation.
History of Treatment
On 03/14/2024, Chen, M.D., at Westside Occupational evaluated the industrial lift and persistent lumbar symptoms. The diagnosis was lumbar strain. Modified duty was started with a 25 lb lifting limit and no repetitive bending, and a physical therapy referral was made. Lumbar radiographs on 03/15/2024 showed no acute osseous abnormality. Physical therapy began 03/22/2024 at Restore PT. Notes document lumbar stiffness and pain with prolonged standing and a plan for core stabilization. A handwritten flow sheet dated 03/29/2024 is flagged illegible, and the summary of that page may be impacted. Lumbar MRI on 04/02/2024 at Pacific Imaging, interpreted by Okada, L., M.D., demonstrates L4-L5 disc displacement. Remaining lumbar levels are described as unremarkable. Laboratory testing on 04/19/2024 showed an elevated WBC with remaining values within reference range. A ketorolac injection was administered on 04/26/2024. Orthopedic consultation on 05/08/2024 with Walsh, S., M.D., reviewed the MRI, continued modified duty and therapy, and did not recommend surgery. Physical therapy was discharged to a home program in July 2024. The most recent PTP note continues modified duty with a 25 lb lifting limit.
Employment History / Job Description
The patient works as a warehouse associate / material handler at County Logistics. Job duties documented in the PTP report include lifting, stacking, and prolonged standing during a shift. Modified duty has continued with a 25 lb lifting limit and no repetitive bending. The deposition excerpt describes the lift at County Logistics and ongoing limits with bending and standing.
Social History
Tobacco and alcohol use are denied in the available records. No regular exercise program is documented. Living situation is not further detailed in the uploaded records.
Source Files & RecordsGarcia_records_FINAL(7)
MRI_lumbar_Garcia(1)
Frequently asked questions
The case overview combines extracted patient details with a narrative of the injury and treatment history, plus relevant employment and social history documented in the uploaded records. Source Files & Records identifies the supporting documents.
Yes. The overview includes supporting records, and the case workspace retains the original files. Check the cited material and individual encounters before using a finding in your report.