Form Pr-2 - Primary Treating Physician'S Progress Report (Pr-2) Sample Page 5
ADVERTISEMENT
1
2
3
4
5
6
7
8RE: CARTER, LINDA J.
DOE: January 12, 2015
Page 5
3. Imaging is indicated only if they have severe progressive
The patient currently complains of constant severe low back
neurologic impairments or signs or symptoms indicating a
pain which she rates as 8/10 on a pain scale, associated with
serious or specific underlying condition.
numbness and tingling sensation radiating to the lower
extremities. The pain is aggravated by lifting heavy objects
or bending, and the patient has difficulty with ambulation.
On examination of the lumbar spine, there is tenderness over
the L3-S1 spinous processes and in the paralumbar muscles,
bilaterally. There is restricted range of motion in all planes.
Neurological examination reveals biceps reflex is diminished
on the left with a grade of 1+. Sensory examination indicates
diminished sensation over the dorsum of the hand, and
sensation testing with a pinwheel is slightly abnormal over
the lumbar spine. Also, the patient is diagnosed with brachial
plexus lesion. The above mentioned findings indicate the
patient may have severe progressive neurological impairment
or signs or symptoms indicating a serious or specific
underlying condition. Therefore, an MRI scan of the lumbar
spine is the appropriate medical procedure that is consistent
with the guidelines and evidence-based medicine.
Work Status: This patient has been instructed to:
Remain off-work until __02/16/2015___.
The patient is temporarily totally disabled.
modified
Return to
work on __________
with the following restrictions or limitations: ______________________________.
Return to full duty on _______________
with no limitations or restrictions.
Primary Treating Physician:
(original signature, do not stamp)
Date of Exam:
01/12/2015
I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code 139.3.
Signature:
Cal. Lic. #:
A11111
Executed at:
San Jose, CA
Date:
01/12/2015
Name:
Bruce Wayne, M.D.
Specialty:
Orthopedic Surgeon
Address:
1111 Forest Avenue, Suite 1111, San Jose CA 95101
Phone:
(408) 555-0111
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal