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Garcia, M.

Records

X-ray — Lumbar Spine

Radiology

X-ray — Lumbar Spine

p. 32

David Chen, M.D.

03/15/2024 · 32–34

32–34

32248

RecordsFiles

27 Records

General (5)

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.

03/14/2024PTP 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.

03/22/2024PT 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.

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.

Diagnostic (3)

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.

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.

Comprehensive (11)

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.

04/28/2024PT 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.

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.

06/20/2024PTP 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.

07/08/2024Therapy 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.

Non-medical (4)

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.

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.

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.

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.

Labs (2)

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.

Operatives (1)

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.

Deposition (1)

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.

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Musculoskeletal conditions with emphasis on diagnoses and treatments.

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Garcia, M.

RecordsFiles

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 & Records

Garcia_records_FINAL(7)

03/12/2024 ER Visit1–4

03/14/2024 PTP Initial Eval5–11

03/15/2024 X-ray — Lumbar Spine32–34

03/22/2024 PT Evaluation45–52

04/02/2024 Therapy Note18–21

06/03/2024 Ortho Consult110–128

08/12/2024 PR-2 Report210–224

MRI_lumbar_Garcia(1)

03/18/2024 MRI — Lumbar Spine12–15

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Was there any treatment for the lumbar spine before the DOI?

Yes. Records document lumbar treatment before the 03/12/2024 date of injury. Pre-injury lumbar care: On 08/14/2018, Patel, Anika, M.D., saw the patient for low-back pain after a non-industrial strain.²⁰ Symptoms included stiffness with bending and prolonged standing. No radiation into the legs was documented. The diagnosis was lumbar strain. A course of physical therapy was recommended. No lumbar surgery and no injection therapy are noted in that record.²¹ No earlier lumbar procedures are documented in the available records. Industrial injury: The 03/12/2024 workplace lift at County Logistics is the first industrial lumbar event in the file. Emergency and PTP records from that date describe immediate low-back pain after lifting a carton.¹⁴ Those visits treat the 2018 care as prior history, not as treatment for this claim. Takeaway: there was pre-DOI lumbar treatment in 2018 (strain and recommended physical therapy), with no documented lumbar surgery. That prior care is non-industrial in the records. Lumbar complaints related to this claim begin on the date of injury.

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