Medical chronology

The treatment history, in order.

MediScan organizes medical encounters by date across the uploaded records. Follow treatment from multiple providers in one chronology, with summaries and source references available for each encounter.

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07/10/2019Qualified Medical Evaluation Report

10-33

Leung, Raymond, MD

HPI: Industrial injury on 01/18/2018 with persistent low back and left leg symptoms.

CC: Low back pain with left radicular symptoms.

DX: Lumbar strain; L4-L5 disc displacement.

Social History: Former smoker; works as warehouse associate.

Discussion: Findings consistent with industrial mechanism; residual impairment expected.

Causation: Industrial, arising out of and in course of employment.

P&S Status: Permanent and stationary as of exam date.

Impairment: DRE Lumbar Category II; 8% WPI.

Apportionment: 80% industrial / 20% non-industrial.

Future Care: Occasional PT, NSAIDs, and follow-up as needed.

Work Status: Permanent modified duty; 25 lb lifting limit.

08/14/2019Progress Report

4-7

Patel, Anika, MD

HPI: Patient reports ongoing left knee pain after workplace fall 6 weeks prior. Pain rated 5/10, worse with prolonged standing.

CC: Left knee pain and intermittent swelling.

DX: Left knee sprain; rule out meniscal injury.

TX: NSAID trial, home exercise program, and activity modification.

Work Status: Modified duty; avoid kneeling and ladder climbing.

04/02/2021MRI Report - Lumbar Spine

12-15

Chen, David, MD

Findings: L4-L5 disc bulge with mild bilateral foraminal narrowing. L5-S1 mild degenerative disc disease. No fracture or marrow edema.

Impression: Mild L4-L5 disc bulge without significant stenosis; correlate clinically.

05/22/2021Orthopedic Follow-Up

18-21

Nguyen, Lisa, MD

HPI: Returns for recheck after 4 weeks of PT. Notes improved ROM but residual morning stiffness.

CC: Residual left knee stiffness.

DX: Improving left knee sprain.

TX: Continue PT 1x/week for 3 additional weeks.

Work Status: May advance to full duty in 2 weeks if progress continues.

06/08/2021MRI Report - Left Knee

22-25

Rivera, Marco, MD

Findings: Mild chondromalacia of medial femoral condyle. Intact ACL/PCL. Small joint effusion. No meniscal tear identified.

Impression: Mild medial compartment chondromalacia without meniscal or ligament tear.

07/10/2019Qualified Medical Evaluation Report

10-33

Leung, Raymond, MD

HPI: Industrial injury on 01/18/2018 with persistent low back and left leg symptoms.

CC: Low back pain with left radicular symptoms.

DX: Lumbar strain; L4-L5 disc displacement.

Social History: Former smoker; works as warehouse associate.

Discussion: Findings consistent with industrial mechanism; residual impairment expected.

Causation: Industrial, arising out of and in course of employment.

P&S Status: Permanent and stationary as of exam date.

Impairment: DRE Lumbar Category II; 8% WPI.

Apportionment: 80% industrial / 20% non-industrial.

Future Care: Occasional PT, NSAIDs, and follow-up as needed.

Work Status: Permanent modified duty; 25 lb lifting limit.

08/14/2019Progress Report

4-7

Patel, Anika, MD

HPI: Patient reports ongoing left knee pain after workplace fall 6 weeks prior. Pain rated 5/10, worse with prolonged standing.

CC: Left knee pain and intermittent swelling.

DX: Left knee sprain; rule out meniscal injury.

TX: NSAID trial, home exercise program, and activity modification.

Work Status: Modified duty; avoid kneeling and ladder climbing.

04/02/2021MRI Report - Lumbar Spine

12-15

Chen, David, MD

Findings: L4-L5 disc bulge with mild bilateral foraminal narrowing. L5-S1 mild degenerative disc disease. No fracture or marrow edema.

Impression: Mild L4-L5 disc bulge without significant stenosis; correlate clinically.

05/22/2021Orthopedic Follow-Up

18-21

Nguyen, Lisa, MD

HPI: Returns for recheck after 4 weeks of PT. Notes improved ROM but residual morning stiffness.

CC: Residual left knee stiffness.

DX: Improving left knee sprain.

TX: Continue PT 1x/week for 3 additional weeks.

Work Status: May advance to full duty in 2 weeks if progress continues.

06/08/2021MRI Report - Left Knee

22-25

Rivera, Marco, MD

Findings: Mild chondromalacia of medial femoral condyle. Intact ACL/PCL. Small joint effusion. No meniscal tear identified.

Impression: Mild medial compartment chondromalacia without meniscal or ligament tear.

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Garcia, M.

Records

ER Visit

Occupational Medicine

ER Visit

p. 1

Anika Patel, M.D.

03/12/2024 · 1–4

1–4

1248

RecordsFiles

27 Records

03/12/2024ER Visit

1–4

Anika Patel, M.D.

HPI: Workplace lift at County Logistics. Immediate lumbar pain, no radiation.

CC: Low-back pain after lifting a carton.

DX: Lumbar strain.

TX: NSAIDs, activity modification, outpatient follow-up.

03/13/2024Claim Form

262–264

County Logistics

HPI: DWC-1 signed the day after the carton lift at County Logistics.

CC: Low-back injury claim.

DX: Not applicable.

TX: Claim opened with Pacific Compensation.

03/14/2024PTP Initial Eval

5–11

Priya Nair, M.D.

HPI: Reports 03/12/2024 carton lift at County Logistics with persistent lumbar pain.

CC: Low-back pain limiting bending and lifting.

DX: Lumbar strain; rule out disc injury.

TX: Off work, NSAID, ice, and imaging ordered.

03/15/2024X-ray — Lumbar Spine

32–34

David Chen, M.D.

Findings: No fracture or listhesis. Mild L4–L5 disc-space narrowing.

Impression: Degenerative change without acute osseous injury.

03/18/2024MRI — Lumbar Spine

12–15

David Chen, M.D.

Findings: L4–L5 disc displacement with mild left foraminal narrowing.

Impression: Findings correlate with reported left radicular symptoms.

03/22/2024PT Evaluation

45–52

Luis Ortega, P.T.

HPI: Started outpatient PT for lumbar strain after the 03/12/2024 lift.

CC: Pain with flexion and sit-to-stand.

DX: Lumbar strain with reduced mobility.

TX: Core stabilization, flexion intolerance education, home program.

04/02/2024Therapy Note

18–21

James Hale, D.C.

HPI: Follow-up for low-back stiffness with left-sided radiation.

CC: Low back stiffness with left-sided radiation.

DX: Lumbar strain with left radicular symptoms.

TX: Spinal manipulation, myofascial release, and home stretching.

04/08/2024Claims Correspondence

255–258

Pacific Compensation

HPI: Carrier letter acknowledging the 03/12/2024 claim and requesting records.

CC: Industrial injury claim correspondence.

DX: Not applicable.

TX: Records request and benefit notice enclosed.

04/11/2024PTP Follow-up

78–84

Priya Nair, M.D.

HPI: MRI reviewed. Residual left-sided symptoms with improved sitting tolerance.

CC: Low-back pain with intermittent left radiation.

DX: Lumbar strain; L4–L5 disc displacement.

TX: Continue PT and chiropractic. Modified duty, 25 lb limit.

04/19/2024CBC

269–270

Pacific Imaging

Findings: WBC mildly elevated. Remaining cell lines within reference range.

Impression: Nonspecific leukocytosis. No other acute hematologic abnormality.

04/19/2024Metabolic Panel

271–272

Pacific Imaging

Findings: Electrolytes, creatinine, and glucose within reference range.

Impression: No metabolic contraindication to NSAID as prescribed.

04/26/2024Ketorolac Injection

273–275

Priya Nair, M.D.

HPI: In-office ketorolac for flare of lumbar pain after prolonged standing.

CC: Acute-on-chronic low-back pain.

DX: Lumbar strain, symptomatic flare.

TX: IM ketorolac administered. Observed and released.

04/28/2024PT Progress Note

90–96

Luis Ortega, P.T.

HPI: Eight visits completed. Morning stiffness improved, lifting still limited.

CC: Pain at end-range flexion.

DX: Improving lumbar strain.

TX: Progressed lumbar stabilization and work-simulation drills.

05/02/2024Wage Statement

259–261

County Logistics

HPI: Employer wage printout covering 13 weeks before the DOI.

CC: Average weekly wage documentation.

DX: Not applicable.

TX: Submitted for temporary disability calculation.

05/03/2024Deposition Excerpt

276–280

M. Garcia

HPI: Applicant describes the carton lift at County Logistics and ongoing bending limits.

CC: Low-back pain after industrial lift.

DX: Not applicable.

TX: Testimony only. No treatment rendered.

05/19/2024Therapy Note

28–31

James Hale, D.C.

HPI: Improved lumbar mobility with residual morning stiffness.

CC: Residual lumbar stiffness, improved radiation.

DX: Improving lumbar strain.

TX: Continued chiropractic adjustments and lumbar stabilization.

06/03/2024Ortho Consult

110–128

Rachel Kim, M.D.

HPI: Referred for persistent L4–L5 symptoms after conservative care.

CC: Low-back pain with left-sided radiation after industrial lift.

DX: Lumbar disc displacement without surgical indication at this time.

TX: Continue non-operative care. Injection deferred.

06/12/2024EMG / NCS

140–146

Omar Shah, M.D.

Findings: Mild left L5 irritability without axon loss. No plexopathy.

Impression: Electrodiagnostic findings support a mild left radiculopathy.

06/20/2024PTP Follow-up

155–162

Priya Nair, M.D.

HPI: EMG reviewed. Patient remains on modified duty at County Logistics.

CC: Activity-limited low-back pain.

DX: Lumbar strain with mild left radiculopathy.

TX: Continue therapy. Re-evaluate MMI in 6–8 weeks.

07/01/2024Records Subpoena

265–268

Valley Ortho QME

HPI: Subpoena for prior Harbor Family Clinic records from 2018.

CC: Prior records request.

DX: Not applicable.

TX: Return of records requested within 15 days.

07/08/2024Therapy Note

168–174

James Hale, D.C.

HPI: Standing tolerance improved. Residual stiffness after warehouse shifts.

CC: End-of-shift lumbar stiffness.

DX: Improving lumbar strain.

TX: Adjustments, hip flexor stretching, and posture cues.

07/22/2024PT Progress Note

180–186

Luis Ortega, P.T.

HPI: Functional lifting improved to 20 lb with good mechanics.

CC: Fatigue with repetitive bending.

DX: Improving lumbar strain.

TX: Work hardening emphasis; continue home program.

08/05/2024PTP Follow-up

198–204

Priya Nair, M.D.

HPI: Ongoing modified duty. No new injury. Symptoms stable.

CC: Intermittent lumbar stiffness.

DX: Lumbar strain, improving.

TX: Maintain 25 lb restriction. No surgery planned.

08/12/2024PR-2 Report

210–224

Priya Nair, M.D.

HPI: Industrial lumbar strain from 03/12/2024 lift, still under conservative care.

CC: Low-back pain with residual left symptoms.

DX: Lumbar strain; L4–L5 disc displacement.

TX: Continued modified duty and therapy. MMI not yet declared.

08/18/2024Therapy Note

228–234

James Hale, D.C.

HPI: Maintenance visit. Radiation largely resolved with residual stiffness.

CC: Mild lumbar stiffness after prolonged standing.

DX: Improving lumbar strain.

TX: Adjustment and home stretching; reduced visit frequency.

08/22/2024Work Status

240–248

Priya Nair, M.D.

HPI: Updated work status for County Logistics modified-duty placement.

CC: Activity-limited low-back pain.

DX: Lumbar strain with residual symptoms.

TX: 25 lb lifting limit, no repetitive bending. Full duty not released.

08/26/2024QME Cover Letter

249–254

Priya Nair, M.D.

HPI: Records packet prepared for orthopedic QME review of the 03/12/2024 injury.

CC: Industrial lumbar strain with residual symptoms.

DX: Lumbar strain; L4–L5 disc displacement.

TX: No change in modified duty pending QME.

Garcia, M.

Records

ER Visit

Occupational Medicine

ER Visit

p. 1

Anika Patel, M.D.

03/12/2024 · 1–4

1–4

1248

RecordsFiles

27 Records

03/12/2024ER Visit

1–4

Anika Patel, M.D.

HPI: Workplace lift at County Logistics. Immediate lumbar pain, no radiation.

CC: Low-back pain after lifting a carton.

DX: Lumbar strain.

TX: NSAIDs, activity modification, outpatient follow-up.

03/13/2024Claim Form

262–264

County Logistics

HPI: DWC-1 signed the day after the carton lift at County Logistics.

CC: Low-back injury claim.

DX: Not applicable.

TX: Claim opened with Pacific Compensation.

03/14/2024PTP Initial Eval

5–11

Priya Nair, M.D.

HPI: Reports 03/12/2024 carton lift at County Logistics with persistent lumbar pain.

CC: Low-back pain limiting bending and lifting.

DX: Lumbar strain; rule out disc injury.

TX: Off work, NSAID, ice, and imaging ordered.

03/15/2024X-ray — Lumbar Spine

32–34

David Chen, M.D.

Findings: No fracture or listhesis. Mild L4–L5 disc-space narrowing.

Impression: Degenerative change without acute osseous injury.

03/18/2024MRI — Lumbar Spine

12–15

David Chen, M.D.

Findings: L4–L5 disc displacement with mild left foraminal narrowing.

Impression: Findings correlate with reported left radicular symptoms.

03/22/2024PT Evaluation

45–52

Luis Ortega, P.T.

HPI: Started outpatient PT for lumbar strain after the 03/12/2024 lift.

CC: Pain with flexion and sit-to-stand.

DX: Lumbar strain with reduced mobility.

TX: Core stabilization, flexion intolerance education, home program.

04/02/2024Therapy Note

18–21

James Hale, D.C.

HPI: Follow-up for low-back stiffness with left-sided radiation.

CC: Low back stiffness with left-sided radiation.

DX: Lumbar strain with left radicular symptoms.

TX: Spinal manipulation, myofascial release, and home stretching.

04/08/2024Claims Correspondence

255–258

Pacific Compensation

HPI: Carrier letter acknowledging the 03/12/2024 claim and requesting records.

CC: Industrial injury claim correspondence.

DX: Not applicable.

TX: Records request and benefit notice enclosed.

04/11/2024PTP Follow-up

78–84

Priya Nair, M.D.

HPI: MRI reviewed. Residual left-sided symptoms with improved sitting tolerance.

CC: Low-back pain with intermittent left radiation.

DX: Lumbar strain; L4–L5 disc displacement.

TX: Continue PT and chiropractic. Modified duty, 25 lb limit.

04/19/2024CBC

269–270

Pacific Imaging

Findings: WBC mildly elevated. Remaining cell lines within reference range.

Impression: Nonspecific leukocytosis. No other acute hematologic abnormality.

04/19/2024Metabolic Panel

271–272

Pacific Imaging

Findings: Electrolytes, creatinine, and glucose within reference range.

Impression: No metabolic contraindication to NSAID as prescribed.

04/26/2024Ketorolac Injection

273–275

Priya Nair, M.D.

HPI: In-office ketorolac for flare of lumbar pain after prolonged standing.

CC: Acute-on-chronic low-back pain.

DX: Lumbar strain, symptomatic flare.

TX: IM ketorolac administered. Observed and released.

04/28/2024PT Progress Note

90–96

Luis Ortega, P.T.

HPI: Eight visits completed. Morning stiffness improved, lifting still limited.

CC: Pain at end-range flexion.

DX: Improving lumbar strain.

TX: Progressed lumbar stabilization and work-simulation drills.

05/02/2024Wage Statement

259–261

County Logistics

HPI: Employer wage printout covering 13 weeks before the DOI.

CC: Average weekly wage documentation.

DX: Not applicable.

TX: Submitted for temporary disability calculation.

05/03/2024Deposition Excerpt

276–280

M. Garcia

HPI: Applicant describes the carton lift at County Logistics and ongoing bending limits.

CC: Low-back pain after industrial lift.

DX: Not applicable.

TX: Testimony only. No treatment rendered.

05/19/2024Therapy Note

28–31

James Hale, D.C.

HPI: Improved lumbar mobility with residual morning stiffness.

CC: Residual lumbar stiffness, improved radiation.

DX: Improving lumbar strain.

TX: Continued chiropractic adjustments and lumbar stabilization.

06/03/2024Ortho Consult

110–128

Rachel Kim, M.D.

HPI: Referred for persistent L4–L5 symptoms after conservative care.

CC: Low-back pain with left-sided radiation after industrial lift.

DX: Lumbar disc displacement without surgical indication at this time.

TX: Continue non-operative care. Injection deferred.

06/12/2024EMG / NCS

140–146

Omar Shah, M.D.

Findings: Mild left L5 irritability without axon loss. No plexopathy.

Impression: Electrodiagnostic findings support a mild left radiculopathy.

06/20/2024PTP Follow-up

155–162

Priya Nair, M.D.

HPI: EMG reviewed. Patient remains on modified duty at County Logistics.

CC: Activity-limited low-back pain.

DX: Lumbar strain with mild left radiculopathy.

TX: Continue therapy. Re-evaluate MMI in 6–8 weeks.

07/01/2024Records Subpoena

265–268

Valley Ortho QME

HPI: Subpoena for prior Harbor Family Clinic records from 2018.

CC: Prior records request.

DX: Not applicable.

TX: Return of records requested within 15 days.

07/08/2024Therapy Note

168–174

James Hale, D.C.

HPI: Standing tolerance improved. Residual stiffness after warehouse shifts.

CC: End-of-shift lumbar stiffness.

DX: Improving lumbar strain.

TX: Adjustments, hip flexor stretching, and posture cues.

07/22/2024PT Progress Note

180–186

Luis Ortega, P.T.

HPI: Functional lifting improved to 20 lb with good mechanics.

CC: Fatigue with repetitive bending.

DX: Improving lumbar strain.

TX: Work hardening emphasis; continue home program.

08/05/2024PTP Follow-up

198–204

Priya Nair, M.D.

HPI: Ongoing modified duty. No new injury. Symptoms stable.

CC: Intermittent lumbar stiffness.

DX: Lumbar strain, improving.

TX: Maintain 25 lb restriction. No surgery planned.

08/12/2024PR-2 Report

210–224

Priya Nair, M.D.

HPI: Industrial lumbar strain from 03/12/2024 lift, still under conservative care.

CC: Low-back pain with residual left symptoms.

DX: Lumbar strain; L4–L5 disc displacement.

TX: Continued modified duty and therapy. MMI not yet declared.

08/18/2024Therapy Note

228–234

James Hale, D.C.

HPI: Maintenance visit. Radiation largely resolved with residual stiffness.

CC: Mild lumbar stiffness after prolonged standing.

DX: Improving lumbar strain.

TX: Adjustment and home stretching; reduced visit frequency.

08/22/2024Work Status

240–248

Priya Nair, M.D.

HPI: Updated work status for County Logistics modified-duty placement.

CC: Activity-limited low-back pain.

DX: Lumbar strain with residual symptoms.

TX: 25 lb lifting limit, no repetitive bending. Full duty not released.

08/26/2024QME Cover Letter

249–254

Priya Nair, M.D.

HPI: Records packet prepared for orthopedic QME review of the 03/12/2024 injury.

CC: Industrial lumbar strain with residual symptoms.

DX: Lumbar strain; L4–L5 disc displacement.

TX: No change in modified duty pending QME.

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