SAMPLE FORM
MEDICAL CHRONOLOGY OF INJURED PARTY
DATE OF BIRTH: 12/22/52
DATE OF ACCIDENT: 6/11/2002
Includes Records From:
 Kenly EMS
 Wilson Medical Center
 Wilson Orthopaedic Surgery and Neurology Ctr – Dr.Vanden Bosch
 Kenly Medical Associates
 Comprehensive Rehab
 Pitt County Memorial Hospital
 Center for Scoliosis & Spinal Surgery, PLLC
 Johnston Memorial Hospital
CONFIDENTIAL AND PRIVELEGED INFORMATION: Prepared at the direction of the attorney of and/or related to litigation. Any opinions are for consulting purposes only.
DATE
SOURCE/PG#
PROVIDER
KENLY EMS
6/11/02 000001000002
EMS
EVENT
REVIEWER’S
COMMENTS
Hwy 581 and Hwy 42, Wilson. Sites of Injury: back/spine. Complaining of lower
back pain. Patient stated he had lower back pain going down his left leg. Patient
complaint of no other. History: arthritis, chronic back pain, surgery x 2 lower back
and x 1 on neck. Patient was standing in front of truck complaining of back pain.
Patient stated pain is a 5 on pain scale, minor damage noted to the front of truck.
Patient transported to Wilson ER>
WILSON MEDICAL CENTER
6/11/02 000001
Emergency Dept. MVA – complaint of low back pain radiating down left leg. Rates
L. Ward, RN
pain at 5. Belted driver – moderate “t-bone” impact. History: back surgery x 2. NTN,
arthritis back, hands, feet. Medications: Vicodin, Torpol. Celebrex. Came in via
ambulance and on stretcher.
6/11/02 000002
Pain exacerbated by positioning and movement. Has extremity pain. HEENT: neck
supple/ NT. Impression: back strain, MVA, lumbar pain acute increase chronic
pain.
Injured Party – DOA: 6/11/02
Prepared: 2/7/2006
Back pain and
left leg pain.
Back strain
Increase chronic
pain
Page 1 of 3
Sensation/Motion Intact for left leg.
6/11/02 000006
Diagnosis Spine: MVA; lower back pain. Patient is status post fusion from L4-S1
with transpedicular screws and rods. No hardware complication. No fracture or
subluxation. Impression: status post fusion, L4-S1, without evidence of acute
trauma.
6/24/02 000019Lumbar Myelogram: status post posterior fusion now with increasing back pain and
000021
lower extremity symptoms, left greater than right. Findings: Post-op changes from
posterior fusion extending from L4 through L5-S1 identified. Findings suspicious for
a high-grade central canal spinal stenosis seen extending from L3-L4 level through
L4-L5. Post-op changes seen from posterior fusion extending from L4-L5 and L5S1. Findings suspicious for high-grade central spinal canal stenosis. CT Lumbar
Spine: Impression: high-grade central spinal stenosis at L3-L4 secondary to
diffuse disc bulge and significant thickening of ligamentum flavum posteriorly
and posterior facet joint hypertrophy. Post-op changes S/P posterior fusion at
L4-L5 and L5-S1.
WILSON ORTHOPAEDIC SURGERY AND NEUROLOGY CENTER, PA - G. VANDEN BOSCH
6/12/02
000001
Refill on Vicodin # 60 Walmart
6/18/02
000001
Has been doing relatively well with his back. Still having chronic low back pain as
expected but was in an auto accident 6/11/02. Since then he has had significant
increase in the low back pain with radiation down the left lower extremity of
the foot. In the past he has always had radiation of pain in the right lower extremity.
No particular paresthesias are involved here. Exam – pain to any extension of back.
Tenderness in left lower back to palpation but no trigger points noted. He has
minimal discomfort to forward flexion. Has a negative SLR on right and positive
SLR at 30 to 40 degrees on left with positive Lasegue’s sign. Has no motor
deficit but it is hard to judge sensation deficits since he has chronic sensation
deficits on the right lower extremity from radiculopathy in the past. I think given his
history of 2 level lumbar fusion in the past, I think it is imperative to go ahead with a
myelogram and post myelogram CT to evaluate not only the effusion but the
possibility of nerve root impingement causing left sided radiculopathy. I have given
him Percocet 5 mg. #80 for pain.
7/03/02
000005
Continues to have severe low back pain radiating down both lower extremities, left
worse than right. A myelogram showed fusion to be intact, however, there is
Injured Party – DOA: 6/11/02
Prepared: 2/7/2006
High grade
spinal stenosis
at L3-L4
secondary to
diffuse disc
bulge…
Neck pain
Increase in low
back pain.
New symptoms
- Radiation
down left lower
extremity.
New medication
of Perocet 5 mg.
#80
Significant
midline bulge at
Page 2 of 3
significant central stenosis with a midline bulge of the disk at L3-4 which is the level L3-4 level above
above the fusion. Going ahead with epidural injection at that level directed to the prior fusion.
left. I will see him back following injection. Given Percocet #80 for pain.
Injured Party – DOA: 6/11/02
Prepared: 2/7/2006
Page 3 of 3