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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.

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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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