Patient demographics: (b)(6).It was reported that on, on (b)(6) 2009, patient underwent following procedure: hardware removal from lumbar spine; exploration of lumbar fusion at l4-5; l3 laminectomy with bilateral l3-4 medial facetectomies and foraminotomies; l3-4 posterolateral fusion; l3-4 posterior lumbar interbody fusion; posterior instrumentation at l3-4; insertion of intervertebral cage at l3-4; use of local bone graft, rhbmp-2, and bone graft matrix; bilateral lower extremity triggered emg monitoring.Pre-op diagnosis was: painful retained lumbar hardware; lumbar spinal stenosis; degenerative instability at l3-4, adjacent segment to degeneration.No complications were reported as a result of this surgery.Per op notes: the disk space was grafted with a composite of rhbmp-2 and bone graft followed by insertion of an appropriate sized crescent cage made of peek filled with rhbmp-2.On (b)(6) 2009, patient presented for follow-up 2 weeks' postoperative lumbar fusion at l3-4.Patient reported bilateral arm numbness.Radiographs show his implant stable in position, overall alignment well maintained.On (b)(6) 2009, patient underwent comprehensive counseling for hardware removal, l3 laminectomy, l3-4 posterior lumbar interbody fusion with instrumentation, cage, and bone graft.On (b)(6) 2009, patient presented for follow up two months post lumbar fusion of l3-4.Patient reported left hip and lower back pain.Plain radiograph films of the lumbar spine, ap and lateral, showed the hardware well placed, stable, and in position with no other acute findings.On (b)(6) 2009, patient presented for follow-up for low back pain, hypertension, anxiety and depression.On (b)(6) 2009, patient presented for follow-up and refill of medication for low back pain, hypertension, anxiety and depression.On (b)(6) 2009, patient presented for follow-up for low back pain, hypertension, anxiety and depression.On (b)(6) 2009, patient presented for follow-up for low back pain, hypertension, anxiety and depression.On (b)(6) 2009, patient presented for follow-up and medication fill up for low back pain, hypertension, anxiety and depression.On (b)(6) 2010, patient underwent x-ray.Impression: no acute fracture or dislocation of foot.On (b)(6) 2010, patient presented with right ankle fracture, patient reported a fall and twisted his right lower extremity.He experienced immediate lateral right ankle pain and noted deformity.Patient underwent x-ray of right ankle, impression: right ankle bimalleolar equivalent with displaced distal fibular diaphyseal fracture.Doctor recommended surgery for the fracture.Prior to fracture patient used cane for ambulation.On (b)(6) 2010, patient presented for follow-up for low back pain, hypertension, anxiety and depression.On (b)(6) 2010, patient presented for follow up post orif of right distal fibula.Patient underwent ap, lateral, and mortise view x-rays of the right ankle, impression: status post orif, right ankle lateral malleolus (weber c) fracture doing well.Early crps.On (b)(6) 2010, patient presented for follow up post orif of right distal fibula.On (b)(6) 2010, patient presented for follow-up for low back pain, hypertension, anxiety and depression.On (b)(6) 2010, patient presented for follow up post orif of right distal fibula.On (b)(6) 2010, patient presented for follow up post orif of right distal fibula.On (b)(6) 2010, patient presented for follow-up for low back pain, hypertension, anxiety and depression.On (b)(6) 2010, patient reported back pain and depression.On (b)(6) 2010, patient presented with persistent spinal complaints, plain radio graph films of the cervical area showed a well-healed fusion, no additional findings noted, no proximal adjacent segment degenerative changes.Lumbar films, ap and lateral, showed an unconvincing fusion with minimal intervertebral ossification.The thoracic area does showed some degenerative changes, ddd, and vertebral height loss.On (b)(6) 2010, patient presented for follow up presented for follow-up for low back pain, hypertension, anxiety and depression.Patient underwent thoracic mri.Patient reported lower back pain and a sensation of instability in the area that was not resolved from his previous fusion approximately one year ago.Mri of the thoracic area showed some stenosis at t4-5 and ts-6, which is consistent with his symptoms.On (b)(6) 2010, patient presented for follow-up for low back pain, hypertension, anxiety and depression.Post epidural injections pain was better.On (b)(6) 2011, patient presented for a follow up for low back pain, hypertension, anxiety and depression.On (b)(6) 2011, patient presented for a follow up for low back pain, hypertension and depression.On (b)(6) 2011, patient presented for a follow up for low back pain, hypertension and depression.On (b)(6) 2011, patient reported getting dizzy and passing out followed by palpitation and pain in chest.Patient underwent x-ray which shoed clear lungs with normal pulmonary vessels.On (b)(6) 2011, patient presented for follow up and reported hallucinating.Patient was in hospital for fainting.On (b)(6) 2011, patient presented for a follow-up and getting refill of medication and reported low back pain.On (b)(6) 2011, patient presented for a follow-up and getting refill of medication.On (b)(6) 2011, patient was involved in a mvc and reported pain in neck, lower thoracic and upper lumbar spine, pelvis, upper and lower leg and right ankle.On (b)(6) 2011, patient underwent x-ray after mvc.Impression: stable findings, no evidence of acute traumatic injury.On (b)(6) 2011, patient was involved in mvc on (b)(6) 2011, and reported pain in back, neck and teeth after accident.Patient underwent ct which showed fusion instrumentation in stable position and no fractures were observed.On (b)(6) 2011, patient reported with back pain which had worsened since accident.On (b)(6) 2012, patient reported chronic pain due to trauma.On (b)(6) 2012, patient presented for follow up for depression.On (b)(6) 2012, patient presented for follow up for back pain.On (b)(6) 2012, patient presented for follow-up.On (b)(6) 2012, patient presented for follow-up.Patient had a car accident and had neck, rib and backpain due to accident.
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