Taylor Brown

  
 General Appearance: The patient is well-developed, well-nourished, and in no distress. He is 
 alert and oriented X 3. The patient ambulates to the examination room without assistive device. 
 He is able to sit comfortably. 
 Spine: 
 LUMBAR: Range of motion is restricted with flexion limited to 10 degrees limited by pain and 
 extension limited to 15 degrees limited by pain. 

 SPECIAL TEST: Straight leg raising test is positive on both sides. 
 OTHER: Motor Strength: Quadraceps R 4/5, L 4+/5, Hamstrings R 4/5, L 4+/5. 
 Diagnosis: 
 722.52 
 Lumbar or Lumbosacral Disc Degeneration 
 722.10 
 Lumbar Disc Displacement Without Myelopathy 
 724.4 
 Thoracic or Lumbosacral Neuritis or Radiculitis Not Otherwise Specified 
 Plan: 
 RTC X 4 weeks. Request authorization for R sided L4, L5, S transforaminal epidural injection. 
 Meds refilled. Continue ice, heat, meds, exercise. 
 Work Status: 
 Patient is Temporarily Totally Disabled until the next appointment. 
 Followup: 
 4 Week(s) WC Follow-up 
 Patient: Taylor Brown 
 DOB: 97-04-02 Visit: 23-04-15 Page: 59
 659
