INFUSE BONE GRAFT
Report
- Report Number
- 1030489-2013-00486
- Event Type
- Injury
- Date Received
- February 14, 2013
- Report Date
- January 25, 2016
- Manufacturer
- MEDTRONIC SOFAMOR DANEK USA, INC
- Product Code
- NEK
- PMA / PMN Number
- P000058
- Adverse Event
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- US
- Reporter Occupation
- PATIENT
Narratives
(B)(4)
(B)(4).
(B)(4).
(B)(4).
(B)(4).
(B)(4).
(B)(4): NEITHER THE DEVICE NOR FILMS OF APPLICABLE IMAGING STUDIES WERE RETURNED TO THE MANUFACTURER FOR EVALUATION. THEREFORE, WE ARE UNABLE TO DETERMINE THE DEFINITIVE CAUSE OF THE REPORTED EVENT. PRODUCTS FROM MULTIPLE MANUFACTURERS WERE USED DURING THE PROCEDURE. ALTHOUGH IT IS UNKNOWN IF ANY OF THE DEVICES CONTRIBUTED TO THE REPORTED EVENT, WE ARE FILING THIS MDR FOR NOTIFICATION PURPOSES.
(B)(4).
IT WAS REPORTED THAT THE PATIENT UNDERWENT A SPINAL FUSION SURGERY AT L3 TO L5 USING RHBMP-2/ACS ON (B)(6) 2008. PATIENT'S POST-OPERATIVE PERIOD HAD PERSISTENT BACK PAIN THAT RADIATES TO HIS LOWER EXTREMITIES. THE PATIENT SUFFERED A SEVERE INFLAMMATORY REACTION, DESTABILIZATION OF HIS FUSION AND ULTIMATELY HARDWARE FAILURE. THE PATIENT DEVELOPED ECTOPIC BONE GROWTH THAT EMERGES FROM THE IMPLANT SITE AND COMPRESSES THE EXITING NERVE ROOTS, RESULTING IN SEVERE PAIN. PATIENT CONTINUES TO EXPERIENCE CHRONIC LOWER BACK AND LEG PAIN.
IT WAS REPORTED THAT ON (B)(6) 2007: THE PATIENT WAS DIAGNOSED WITH FAINTING SPELLS, MEMORY PROBLEM, INSTABILITY TO CONCENTRATION, BLURRED VISION, ANXIETY, AND DEPRESSION. ON (B)(6) 2007: THE PATIENT PRESENTED WITH CHIEF COMPLAINT OF NECK AND BACK PAIN. ON (B)(6) 2007: THE PRESENTED FOR OFFICE VISIT. ON (B)(6) 2007: THE PATIENT UNDERWENT PHYSICAL EXAMINATION. ASSESSMENT: PAIN COMING FROM THE L4-5 LEVEL. HOWEVER FOR THE FORAMINAL STENOSIS AT L4-5 PAIN IN THE ANTERIOR THIGH RATHER THAN IN THE BACK OF THE LEG. ON (B)(6) 2008: THE PATIENT UNDERWENT ABDOMINAL ULTRASOUND. IMPRESSION: NO ACUTE PROCESS. ON (B)(6) 2008: THE PATIENT PRESENTED WITH CRAMPING AND GERD. ON (B)(6) 2008: THE PATIENT PRESENTED WITH PREOPERATIVE DIAGNOSIS OF EPIGASTRIC AND PAIN. AND UNDERWENT EGD WITH BIOPSY. 16 SEP 2008: THE PATIENT PRESENTED FOR FOLLOW UP. ON (B)(6) 2008 THE PATIENT PRESENTED WITH PREOPERATIVE DIAGNOSE OF ESOPHAGEAL STENOSIS AND UNDERWENT EGD WITH BIOPSY AND DILATATION. IMP RESSION: GASTRITIS, ESOPHAGEAL STENOSIS, GERD. ON (B)(6) 2009: THE PATIENT PRESENTED FOR OFFICE VISIT. ON (B)(6) 2009: THE PATIENT UNDERWENT PHYSICAL EXAMINATION. IMPRESSION: ABDOMINAL PAIN, RIGHT SCROTAL PAIN WITH SWELLING MASS. ON (B)(6) 2011: PATIENT PRESENTED WITH BACK, NECK PAIN, HEADACHE, ARM PAIN AND LEG PAIN. ROS REVEALED: MUSCULOSKELETAL: ABDOMINAL PAIN, ANXIETY, ARM PAIN, BALANCE DISTURBANCE, BLOOD IN URINE, CHANGE IN BOWEL HABITS, CHEST PAIN, CHRONIC COUGH, DEPRESSION, BLURRED VISION, HEADACHES, HEART MURMUR, FATIGUE, INCONTINENCE, LEG PAIN, LOW BACK PAIN, NASAL CONGESTION, NAUSEA, NECK PAIN, PAIN IN SWALLOWING, PAINFUL URINATION, MEMORY PROBLEM, SINUS, SHORTNESS OF BREATH, SORE THROAT, SWELLING IN FEET, VOMITING, WEIGHT LOSS. ON (B)(6) 2011: THE PATIENT PRESENTED FOR OFFICE VISIT. THE PATIENT UNDERWENT PHYSICAL EXAMINATION. IMPRESSION: DYSPHAGIA WITH SUBSTERNAL CHEST PAIN, HISTORY OF CAD. ON (B)(6) 2015: THE PATIENT PRESENTED WITH PROBLEM OF SLOW TRANSIT CONSTIPATION. ROS REVEALED: CHANGE IN APPETITE, BACK PAIN, DEPRESSION
IT WAS REPORTED THAT ON (B)(6) 2009: PATIENT UNDERWENT LAPAROSCOPIC NISSEN FUNDOPLICATION FOR A PRE-OP DIAGNOSIS OF REFLUX DISEASE. NO COMPLICATIONS WERE REPORTED DURING THE PROCEDURE. ON (B)(6) 2009: THE PATIENT ALSO UNDERWENT ENDOSCOPY DUE TO DYSPHAGIA (B)(6) 2009 PATIENT REPORTED NECK AND LUMBAR PAIN. CT SCAN SHOWED PROBLEM WITH DISC AND NERVE ROOTS IN LUMBAR AND CERVICAL SPINE. PATIENT'S MRI DOCUMENTED C-SPINE NEUROFORAININAL IMPINGEMENT WITH MILD-TO-MODERATE SPINAL STENOSIS. ON (B)(6) 2010 THE PATIENT REPORTED CRYING SPELLS, ANXIETY WHICH CAUSES EXTREME SWEATING AND SHAKING. ON (B)(6) 2010: PATIENT HAD AN X-RAY ON (B)(6) WHICH SHOWED PEDICLE SCREW FRACTURE AT L5. ON (B)(6) 2010: THE PATIENT REPORTED HEADACHE, NECK PAIN AND THROBBING ON BOTH SIDES AND TINGLING ON BACK OF HEAD. PATIENT REPORTED LOSING HIS VOICE TODAY (B)(6) 2011 THE PATIENT PRESENTED FOR FOLLOW-UP. IMPRESSION: LUMBAR DISC DISEASE; FRACTURE PEDICLE SCREW, 3. LUMBAR PAIN. ON (B)(6) 2011, THE PATIENT'S MRI FROM (B)(6) 2011 REVEALED GRADE I SPONDYLOLISTHESIS AND OTHER CHRONIC CHANGES. IMPRESSION: LUMBAR DISC DISEASE; CERVICAL DISC DISEASE; ADVANCED ANXIETY AND DEPRESSION; CHRONIC PAIN SYNDROME. ON (B)(6) 2011, PATIENT REPORTED LOWER BACK PAIN. PATIENT AMBULATED WITH SLOW STEADY GAIT (B)(6) 2011 THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH NUMBNESS AND TINGLING IN HIS BOTH HANDS. ON (B)(6) 2011 THE PATIENT UNDERWENT A PROCEDURE. PREOPERATIVE DIAGNOSIS: LEFT CARPAL TUNNEL SYNDROME; LOFT ULNAR NERVE COMPRESSION AT THE WRIST. PROCEDURES PERFORMED: LEFT CARPAL TUNNEL RELEASE; GUYON'S CANAL DECOMPRESSION OF THE ULNAR NERVE; VOLAR FOREARM FASCIOTOMY. HE WAS PRESENTED FOR OFFICE VISIT WITH BILATERAL WRIST PAIN. IMPRESSIONS: QUESTION BILATERAL CARPAL TUNNEL SYNDROME. ON (B)(6) 2011 THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH PAIN ALL OVER.
IT WAS REPORTED THAT ON (B)(6) 2005, THE PATIENT UNDERWENT VENTILATION PERFUSION LUNG SCAN. IMPRESSION: NORMAL STUDY. THE PATIENT ALSO UNDERWENT X-RAYS OF THE CHEST. IMPRESSION: NORMAL FRONTAL CHEST. THE PATIENT ALSO UNDERWENT RCTA OF THE CHEST DUE TO SHORTNESS OF BREATH. IMPRESSION: SUBOPTIMAL EXAM TO EXCLUDE PULMONARY EMBOLI. ON (B)(6) 2008, THE PATIENT PRESENTED WITH PRE-OP DIAGNOSIS OF RIGHT C5, C6 AND C7 RADICULOPATHIES. THE PATIENT UNDERWENT THE FOLLOWING PROCEDURES: ANTERIOR CERVICAL DISCECTOMY C4-5, C5-6, AND C6-7 WITH MICROSCOPE. ARTHRODESIS C4-5, C5-6, C6-7 WITH MACHINED ALLOGRAFT FILLED WITH AUTOGRAFT. ANTERIOR CERVICAL PLATING C4-7 USING 15 AND 16 MM SCREWS. NO PATIENT COMPLICATIONS WERE NOTED. X-RAYS DEMONSTRATED UNREMARKABLE ALIGNMENT DURING ACDF FROM C4 THROUGH C7. ON (B)(6) 2008, THE PATIENT UNDERWENT ULTRASOUND STUDY. IMPRESSION: COMPLEX CYSTIC AREA RIGHT EPIDIDYMIS. ON (B)(6) 2008 ,THE PATIENT UNDERWENT CT SCAN OF THE ABDOMEN AND PELVIS WITH CONTRAST. IMPRESSION: UNREMARKABLE ENHANCED CT EXAMINATION OF THE ABDOMEN AND PELVIS. ON (B)(6) 2008, THE PATIENT UNDERWENT X-RAYS OF THE CERVICAL SPINE DUE TO PAIN. IMPRESSION: STATUS POST ANTERIOR CERVICAL DISC FUSION FROM C4 THROUGH C7. NO ACUTE FRACTURE OR SUBLUXATION IS SEEN. NO BONE DESTRUCTION IS SEEN. ON (B)(6) 2008, THE PATIENT PRESENTED WITH PRE-OPERATIVE DIAGNOSES OF EPIGASTRIC PAIN AND RLG PAIN. THE PATIENT UNDERWENT TOTAL COLONOSCOPY WITH BIOPSY. IMPRESSION: COLON POLYP. ON (B)(6) 2008, THE PATIENT PRESENTED FOR A FOLLOW-UP AND COMPLAINED OF LOW BACK PAIN. HE HAS SIGNIFICANT BACK PAIN WITH LEG PAIN INTO HIS RIGHT LEG. ON (B)(6) 2008, THE PRESENTED WITH PRE-OPERATIVE DIAGNOSIS OF L4-5 SPONDYLOLISTHESIS WITH CHRONIC LOW BACK PAIN. THE PATIENT UNDERWENT THE FOLLOWING PROCEDURES: BILATERAL L4 AND L5 NERVE ROOT DECOMPRESSIONS. POSTERIOR LUMBAR INTERBODY FUSION USING HOUR GLASS SPACER SIZE 13 BY 21 MM ALONG WITH AUTOGRAFT AND FLUOROSCOPIC GUIDANCE. TRANSVERSE PROCESS ARTHRODESIS L3 THROUGH L5 USING AUTOGRAFT PLUS BONE MORPHOGENIC PROTEINS PLUS MASTERGRAFT. LEGACY PEDICLE SCREW FIXATIONL3 THROUGH L5 USING 6.5 BY 45 MM SCREWS ALONG WITH POLYETHERETHERKETONE RODS, FLUOROSCOPIC GUIDANCE AND SOMATOSENSORY EVOKED POTENTIAL AND ELECTROMYOGRAM MONITORING. PER THE OP NOTES, THE SURGEON DECORTICATED THE TRANSVERSE PROCESSES AT L3 THROUGH L5 BILATERALLY. AUTOGRAFT, BMP AND MASTERGRAFT WERE PLACED ON THESE AREAS AND A LARGE AMOUNT OF AUTOGRAFT WAS PLACED ON TOP OF THIS. X-RAYS DEMONSTRATED BILATERAL TRANSPEDICULAR SCREWS THROUGH L3, L4 AND L5. INTERBODY GRAFT IS PRESENT AT L4-5 LEVEL. THERE IS MILD ANTEROLISTHESIS OF L4 ON L5 PRESENT. THE POST-OP DIAGNOSES WERE 1. L4-5 SPONDYLOLISTHESIS WITH CHRONIC LOW BACK PAIN 2. L3-4 INSTABILITY/INCOMPETENCY. NO PATIENT COMPLICATIONS WERE NOTED. ON (B)(6) 2008, THE PATIENT UNDERWENT CT SCAN OF THE LUMBAR SPINE DUE TO SEVERE PAIN. IMPRESSION: VERY LIMITED EVALUATION OF THE SURGICAL SITE AT L4-5. THERE IS SOFT TISSUE ATTENUATION IN THIS REGION THAT ABUTS THE THECAL SAC; HOWEVER IT'S VERY DIFFICULTY TO DETERMINE IF THERE IS MASS-EFFECT UPON THE THECAL SAC OR IF THERE IS A POST OP FLUID COLLECTION IN THIS REGION DUE TO DEGREE OF SUSCEPTIBILITY ARTIFACT. THE PATIENT UNDERWENT X-RAYS OF THE LUMBAR SPINE. IMPRESSION: POSTERIOR LUMBAR FUSION L3 THROUGH L5. INTERSPACE GRAFT PRESENT AT L4-5. ON (B)(6) 2008, THE PATIENT WAS DISCHARGED FROM THE HOSPITAL. ON (B)(6) 2008, THE PATIENT UNDERWENT EGD WITH BIOPSY AND DILATION DUE TO ESOPHAGEAL STENOSIS. DIAGNOSIS: MILD REACTIVE GASTRITIS 2. NO HELICOBACTER PYLORI WERE SEEN. IMPRESSION: GASTRITIS, ESOPHAGEAL STENOSIS, GERD. ON (B)(6) 2008, THE PATIENT PRESENTED COMPLAINING OF BACK PAIN AND UNDERWENT X-RAYS OF THE LUMBAR SPINE. IMPRESSION: POSTERIOR LUMBAR FUSION L3 THROUGH L5. NO SIGNIFICANT INTERVAL RADIOGRAPHIC CHANGE. ON (B)(6) 2009, THE PATIENT PRESENTED WITH CHRONIC PAIN IN BOTH ARM AND LEG RADICULOPATHY INTERMITTENTLY. THERE IS PARALUMBAR SPASM WITH SOME PALPABLE TENDERNESS, BUT IS STILL ABLE TO EXHIBIT FULL RANGE OF MOTION OF BOTH ARMS AND BOTH LEGS. IMPRESSION: CERVICAL AND LUMBAR PAIN, STATUS POST SURGERIES AT BOTH LEVELS INCLUDING PEDICLE RODS AND SCREWS. CHRONIC PAIN SYNDROME. ANXIETY. ON (B)(6) 2009, THE PATIENT PRESENTED COMPLAINING OF NECK AND BACK PAIN. THE PATIENT UNDERWENT X-RAY OF THE CERVICAL SPINE DUE TO NECK PAIN. CONCLUSION: ACDF CHANGES FROM C4-7 WITH ABNORMAL LUCENCY WITHIN THE PLATE BELOW THE C5 SCREW, WITHOUT DEMONSTRATED DYNAMIC INSTABILITY. THIS IS CONSISTENT WITH A FRACTURE OF THE ANTERIOR CERVICAL PLATE, NOT NOTED ON THE PRIOR EXAM. THE PATIENT UNDERWENT X-RAY OF THE LUMBAR SPINE DUE TO LOW BACK PAIN. CONCLUSION: NO DEMONSTRATED DYNAMIC INSTABILITY WITH PRIOR POSTERIOR FUSION FROM L3-5. ON (B)(6) 2009, THE PATIENT UNDERWENT X-RAYS OF THE CHEST. IMPRESSION: NORMAL STUDY. ON (B)(6) 2009, THE PATIENT PRESENTED WITH PRE-OPERATIVE DIAGNOSIS OF DYSPHAGIA AND UNDERWENT EGD WITH BIOPSY. IMPRESSION: GASTRITIS. DUODENITIS. ON (B)(6) 2009, THE PATIENT PRESENTED WITH MASSIVE GASTRITIS STATUS POST EGD. HE ALSO HAS GERD AND HAD AN ESOPHAGEAL STENOSIS WHICH WAS DILATED. THE PATIENT ALSO HAD INFECTED LEFT GREAT TOE ULCERATION. ON (B)(6) 2009, THE PATIENT UNDERWENT X-RAYS OF THE ABDOMEN. IMPRESSION: NON SPECIFIC BOWEL GAS PATTERN SEEN. ON (B)(6) 2009, THE PATIENT UNDERWENT CT SCAN OF THE HEAD DUE TO HEAD ACHE. IMPRESSION: UNREMARKABLE CT EXAMINATION OF THE BRAIN. ON (B)(6) 2009, THE PATIENT PRESENTED COMPLAINING OF MIGRAINE HEADACHES THAT HE HAS BEEN EXPERIENCING FOR THE PAST COUPLE OF WEEKS. ASSESSMENT: HEADACHE. PERSISTENT NECK AND BACK PAIN. ON (B)(6) 2009, THE PATIENT UNDERWENT MRI OF THE LUMBAR SPINE WITH AND WITHOUT CONTRAST. IMPRESSIONS: POST SURGICAL CHANGES WITH POSTERIOR FUSION OF L3 THROUGH L5. ASSOCIATED POST SURGICAL CHANGES SEEN STABLE ANTEROLISTHESIS L4 ON L5. MILD DEGENERATIVE CHANGES WITH EXIT FORAMINAL NARROWING L4-5 AND L5-S1. ANNULAR TEAR AT L5-S1 SEEN. THE PATIENT UNDERWENT MRI OF THE CERVICAL SPINE WITH AND WITHOUT CONTRAST. IMPRESSIONS: FINDINGS CONCERNING FOR PROTRUSION OF SURGICAL SCREW THROUGH VERTEBRAL BODY INTO THE SPINAL CANAL TO THE LEFT OF MIDLINE AT C6-7. ON (B)(6) 2009, THE PATIENT COMPLAINED THAT HIS REFLUX IS GETTING REFLUX. IMPRESSION: GERD REFRACTORY, HISTORY OF ALCOHOL ABUSE AND DEGENERATIVE JOINT DISEASE SPINE. THE PATIENT PRESENTED WITH PRE-OPERATIVE DIAGNOSIS OF REFLUX DISEASE AND UNDERWENT LAPAROSCOPIC NISSEN FUNDOPLICATION. NO PATIENT COMPLICATIONS WERE NOTED. ON (B)(6) 2009, THE PATIENT PRESENTED WITH PERSISTENT NECK AND BACK PAIN. ASSESSMENT: POST HIATAL HERNIA REPAIR. PERSISTENT NECK AND BACK PAIN. ON (B)(6) 2009, THE PATIENT PRESENTED WITH NECK PAIN AND HEADACHES. DIAGNOSIS: CHRONIC PAIN. ON (B)(6) 2009, THE PATIENT PRESENTED WITH NECK AND BACK PAIN. HE STILL HAS SOME NUMBNESS AND TINGLING IN HIS RIGHT THUMB. HE ALSO HAS INTERMITTENT PAIN IN HIS LEGS. DIAGNOSES: CHRONIC NECK AND BACK PAIN. STATUS POST CERVICAL CORPECTOMIES. STATUS POST LUMBAR FUSION. ON (B)(6) 2009, THE PATIENT PRESENTED FOR A FOLLOW UP VISIT AND UNDERWENT SOME NERVE FUNCTION STUDIES. IT DID SHOW SOME ABNORMALITY OF THE RIGHT ARM RADIAL NERVE INVOLVEMENT ABNORMALITY. THE PATIENT IS ALSO HAVING SOME MIXED VASCULAR HEADACHE PRIMARILY AT THE RIGHT SIDE INVOLVING THE POSTERIOR OCCIPITAL AREA. THE PATIENT ALSO HAS PARACERVICAL SPASM AND TENDERNESS WITH POSITIVE PHALEN AND TINEL SIGN OF THE RIGHT WRIST OVER THE RADIAL NERVE. IMPRESSION: MIXED VASCULAR HEADACHE. CHRONIC LUMBAR PAIN SYNDROME. HISTORY OF HIATAL HERNIA. CHRONIC C-SPINE DISC DISEASE. ON (B)(6) 2009, THE PATIENT PRESENTED COMPLAINING OF MIDLINE POSTERIOR CERVICAL PAIN WITH RADIATION TO THE RIGHT PARACERVICAL, TRAPEZIUS AND RIGHT ARM. THERE IS STRONG BILATERAL HAND GRASP. IMPRESSION: LUMBAR DISC DISEASE. CHRONIC PAIN SYNDROME. C-SPINE DISC DISEASE, RIGHT ARM RADICULOPATHY. ON (B)(6) 2009, THE PATIENT UNDERWENT X-RAYS OF THE CERVICAL SPINE DUE TO NECK PAIN. IMPRESSION: NO ACUTE PROCESS IS IDENTIFIED. CHRONIC AND POST OPERATIVE CHANGES ARE SEEN. ON (B)(6) 2009 ,THE PATIENT PRESENTED FOR A FOLLOW-UP VISIT WITH SOMEWHAT DISTRAUGHT. IMPRESSION: LUMBAR DISC DISEASE. CHRONIC PAIN SYNDROME. REACTIVE ANXIETY AND DEPRESSION. ERECTILE DYSFUNCTION. ON (B)(6) 2009, THE PATIENT UNDERWENT CT SCAN OF THE CERVICAL SPINE DUE TO NECK PAIN. IMPRESSION: CHRONIC AND DEGENERATIVE AS WELL AS POST OPERATIVE CHANGES ARE SEEN THROUGHOUT. THERE IS EVIDENCE OF LEFT SIDED EXIT FORAMINAL STENOSIS AT C5-6 AND C6-7 DUE TO DEGENERATIVE CHANGE. THERE IS EVIDENCE OF MILD EXIT FORAMINAL STENOSIS ON THE RIGHT AT C4-5. ON (B)(6) 2009, THE PATIENT PRESENTED WITH LUMBAR AND NECK PAIN. HE HAS HAD 8.5 POUND WEIGHT GAIN SINCE LAST VISIT. IMPRESSION: C-SPINE AND LUMBAR DISC DISEASE. HISTORY OF VASCULAR HEADACHE. CHRONIC PAIN SYNDROME. ON (B)(6) 2009, THE PATIENT UNDERWENT X-RAYS OF THE CHEST DUE TO CHEST PAIN. IMPRESSION: NO ACUTE PROCESS. ON (B)(6) 2009, THE PATIENT PRESENTED WITH FACIAL NUMBNESS AND UNDERWENT CAROTID DUPLEX ULTRASOUND EXAMINATION. FINDINGS: THERE IS NO HEMODYNAMICALLY SIGNIFICANT STENOSIS NOTED IN THE INTERNAL CAROTID ARTERIES. THERE IS BILATERAL VERTEBRAL ARTERY PATENCY WITH ANTEGRADE FLOW. ON (B)(6) 2009, THE PATIENT UNDERWENT X-RAYS OF THE ABDOMEN DUE TO GROIN PAIN. IMPRESSION: NON SPECIFIC BOWEL GAS PATTERN. ON (B)(6) 2009, THE PATIENT WAS ADMITTED WITH SEVERE RIGHT SCROTAL PAIN AND SWELLING AS WELL AS SEVERE ABDOMINAL PAIN, NAUSEA AND VOMITING WHICH IS INTRACTABLE. THE PATIENT UNDERWENT CT SCAN OF THE ABDOMEN AND PELVIS DUE TO UNEXPLAINED PAIN. IMPRESSION: NEGATIVE ACUTE CT EXAMINATIONS. ON (B)(6) 2009, THE PATIENT UNDERWENT ULTRASOUND STUDY OF THE SCROTUM DUE TO SCROTAL PAIN. IMPRESSION: SMALL BILATERAL VARICOCELES. NEGATIVE OTHERWISE. ON (B)(6) 2009, THE PATIENT PRESENTED WITH PRE-OPERATIVE DIAGNOSIS OF DYSPHAGIA. THE PATIENT UNDERWENT EGD WITH BIOPSY. IMPRESSION: GA STRITIS. INTACT NISSEN REPAIR. THE POST-OPERATIVE DIAGNOSIS IS GASTRITIS. ON (B)(6) 2010, THE PATIENT PRESENTED FOR A FOLLOW UP VISIT WITH THE FOLLOWING IMPRESSIONS: URI, BRONCHITIS. C-SPINE AND LUMBAR DISC DISEASE. MIXED ANXIETY AND DEPRESSION. HYPOGONADISM. ON (B)(6) 2010, THE PATIENT UNDERWENT X-RAYS OF THE ABDOMEN DUE TO PAIN. IMPRESSION: UNREMARKABLE THREE VIEW ABDOMEN SERIES AND CHEST IS CLEAR. ON (B)(6) 2010, THE PATIENT UNDERWENT CT SCAN OF THE ABDOMEN AND PELVIS DUE TO RIGHT FLANK PAIN. IMPRESSION: CT STUDY LIMITED FOR RENAL PROTOCOL. NO URETERAL STONES EVIDENT. BOTH LUNG BASES ARE CLEAR. ON (B)(6) 2010, THE PATIENT PRESENTED WITH PARACERVICAL SPASM AND TENDERNESS WITH REDUCED RANGE OF MOTION ON ALMOST ALL RANGES OF MOTION OF C-SPINE. IMPRESSION: CERVICAL SPINE DISC DISEASE. ANXIETY DISORDER. ON (B)(6) 2010, THE PATIENT PRESENTED WITH C-SPINE PAIN WITH INTERMITTENT ARM AND HAND RADICULOPATHY. IMPRESSION: CERVICAL DISC DISEASE. ANXIETY DISORDER. LUMBAR PAIN SYNDROME. ON (B)(6) 2010, THE PATIENT PRESENTED WITH THE FOLLOWING IMPRESSIONS: C-SPINE AND LUMBAR DISC DISEASE WITH PRIOR SURGERY. INSOMNIA. ANXIETY. HISTORY OF VASCULAR HEADACHE. REACTIVE AIRWAY DISEASE. ON (B)(6) 2010, THE PATIENT PRESENTED WITH WEAKNESS AND FACIAL DROOP. HE ALSO REPORTED GNAWING PAIN ON THE RIGHT AND BACK SIDE OF HIS HEAD. HE ALSO COMPLAINED OF NAUSEA/VOMITING, FATIGUE, CHEST PAIN LOCATED CENTRALLY THAT RADIATES INTO HIS RIGHT AXILLA AND SHORTNESS OF BREATH AND TINGLING IN THE CORNER OF HIS MOUTH ON THE RIGHT SIDE. THE PATIENT UNDERWENT X-RAYS OF THE CHEST. IMPRESSION: NO ACUTE DISEASE ON LOW VOLUME FILM. THE PATIENT UNDERWENT CT SCAN OF THE HEAD. IMPRESSION: NORMAL NON CONTRAST CT OF BRAIN. ON (B)(6) 2010, THE PATIENT PRESENTED WITH TIA, RIGHT SIDED FACIAL AND BODY NUMBNESS AND WEAKNESS. THE NUMBNESS WAS 90% RESOLVED. DIAGNOSES: RECURRENT TIA WITH RIGHT SIDE WEAKNESS AND NUMBNESS. CEREBRAL VASCULAR DISEASE. THE PATIENT ALSO UNDERWENT CAROTID DUPLEX ULTRASOUND EXAMINATION. FINDINGS: THERE IS NO HEMODYNAMICALLY SIGNIFICANT STENOSIS NOTED IN THE INTERNAL CAROTID ARTERIES. THERE IS BILATERAL VERTEBRAL ARTERY PATENCY WITH ANTEGRADE FLOW. ON (B)(6) 2010, THE PATIENT UNDERWENT MRI OF THE BRAIN WITHOUT GADOLINIUM. IMPRESSION: NORMAL STUDY. THE PATIENT UNDERWENT MRI OF THE CIRCLE OF WILLIS. IMPRESSION: NORMAL EXAMINATION. ON (B)(6) 2010, THE PRESENTED WITH CERVICAL SPINE PAIN AND LUMBAR SPINE PAIN WITH SOME DEGENERATIVE DISC DISEASE WITH CHRONIC PAIN. IMPRESSION: LUMBAR AND CERVICAL SPINE DISC DISEASE. ON (B)(6) 2010, THE PATIENT PRESENTED WITH CERVICAL SPINE PAIN AND LUMBAR SPINE PAIN. IMPRESSION: LUMBAR AND CERVICAL SPINE DISC DISEASE. MIXED ANXIETY AND DEPRESSION. ON (B)(6) 2010, THE PATIENT PRESENTED WITH PARACERVICAL TENDERNESS AS WELL AS PARALUMBAR SPASM AND TENDERNESS. IMPRESSION: BORDERLINE HYPERTENSION. ANXIETY DISORDER. LUMBAR AND CERVICAL SPINE DISC DISEASE. ON (B)(6) 2010, THE PATIENT PRESENTED WITH PARACERVICAL PAIN AND PARALUMBAR PAIN. IMPRESSION: CERVICAL SPINE PAIN. LUMBAR SPINE PAIN. INSOMNIA. ANXIETY. GASTROENTERITIS. ON (B)(6) 2010, THE PATIENT UNDERWENT X-RAYS OF THE LUMBOSACRAL SPINE. IMPRESSION: POST OPERATIVE CHANGES WITHIN THE LUMBAR SPINE. ON (B)(6) 2010, THE PATIENT COMPLAINED OF FRUSTRATION AT UNRESOLVED SYMPTOMS THAT APPEARED TO BE DESCRIBED AS CHRONIC INSOMNIA, CHRONIC PAIN AND NON SPECIFIC ANXIETY. ON (B)(6) 2010, THE PATIENT PRESENTED WITH CENTRAL LUMBAR TENDERNESS WITH PARALUMBAR SPASM. IMPRESSION: FRACTURE OF PEDICLE SCREW AT L5. LUMBAR PAIN SYNDROME. MIXED ANXIETY AND DEPRESSION. ON (B)(6) 2010, THE PATIENT UNDERWENT X-RAYS OF THE CERVICAL SPINE. IMPRESSION: STATUS POST ANTERIOR CERVICAL FUSION AT C4-5, C5-6 AND C6-7. DEGENERATIVE CHANGES WITHOUT ACUTE BONY FINDINGS. ON (B)(6) 2010, THE PATIENT PRESENTED COMPLAINING OF LEFT EAR PAIN. THE PATIENT'S MEDICATION TRAZODONE WAS INCREASED TO 100 MG. IMPRESSION: FRACTURE OF PEDICLE SCREW AT L5. LEFT SEROUS OTITIS MEDIA. PANSINUSITIS. INSOMNIA. ON (B)(6) 2011, THE PATIENT PRESENTED WITH BACK AND LEFT LEG PAIN. DIFFICULTY WITH HIS GAIT SECONDARY PAIN. IMPRESSION: INCREASING LOW BACK PAIN WITH CONCERN FOR ADJACENT LEVEL DEGENERATION. ON (B)(6) 2011, THE PATIENT PRESENTED HAVING MOST OF THE TEETH OF HIS MANDIBLE REMOVED SURGICALLY AND HE ALSO CONTINUED WITH PARALUMBAR SPASM AND TENDERNESS. ON (B)(6) 2011, THE PATIENT UNDERWENT MRI OF THE LUMBAR SPINE WITHOUT CONTRAST. IMPRESSION: STABLE EXAMINATION WITH POST SURGICAL CHANGES AND FUSION OF L3 THROUGH L5. STABLE SPONDYLOLISTHESIS L4 ON L5. ON (B)(6) 2011, THE PATIENT'S MEDICATION DURAGESIC PATCH WAS DISCONTINUED AND MSER WAS PRESCRIBED TO HIM FOR CHRONIC PAIN. ON (B)(6) 2011, THE PATIENT UNDERWENT X-RAY OF THE CHEST. IMPRESSION: INCREASED PERIHILAR MARKINGS THE DOCTOR COULD NOT INCLUDE A MILD BR ONCHITISXXXX OR VIRAL PROCESS BUT THIS COULD BE EXAGGERATED DUE TO LUNG VOLUMES. THE PATIENT UNDERWENT X-RAY OF THE LUMBOSACRAL SPINE. IMPRESSION: POST FIXATION HARDWARE WITHIN THE LOWER LUMBAR SPINE. THE PATIENT UNDERWENT CT SCAN OF THE STONE PROTOCOL. IMPRESSION: NO SIGNIFICANT CHANGE AS COMPARED TO PREVIOUS CT. THERE IS NO CALCIFICATIONS INVOLVING EITHER KIDNEY NO HYDRONEPHROSIS AND THE BLADDER IS UNREMARKABLE. ON (B)(6) 2011, THE PATIENT'S MEDICATION ELAVIL WAS INCREASED TO 75 MGS. ON (B)(6) 2011, THE PATIENT PRESENTED WITH PARACERVICAL AND PARALUMBAR SPASM AND TENDERNESS. IMPRESSION: LUMBAR DISC DISEASE. LUMBAR AND CERVICAL PAIN SYNDROME. ANXIETY SYNDROME. ON (B)(6) 2011, THE PATIENT PRESENTED COMPLAINING OF PAIN OF THE LUMBAR AREA HAVING A KNOWN FRACTURED PEDICLE SCREW AT L5. IMPRESSION: FRACTURED PELVIS SCREW. L5 LUMBAR PAIN SYNDROME. ANXIETY SYNDROME. ON (B)(6) 2011, THE PATIENT PRESENTED FOR A FOLLOW-UP IN MEDICATION MANAGEMENT. SHORTNESS OF BREATH AND A RAPID HEART RATE OCCURS DURING ANXIETY EPISODES. HE COMPLAINED OF DIFFICULTY THINKING CLEARLY. DIAGNOSES: POLY SUBSTANCE ABUSE AND MOOD DISORDER. ON (B)(6) 2011, THE PATIENT UNDERWENT X-RAYS OF THE CERVICAL SPINE. FINDINGS: ANTERIOR CERVICAL DISC FUSION. NO EVIDENCE OF COMPRESSION FRACTURE. ON (B)(6) 2011, THE PATIENT UNDERWENT ELECTROPHYSIOLOGICAL EVALUATION FOR PAIN, NUMBNESS AND TINGLING IN THE UE¿S. FINDINGS: SLIGHTLY PROLONGED DISTAL LATENCIES IN THE ULNAR SENSORY NERVE STUDIES BILATERALLY AND IN THE RIGHT MEDIAN SENSORY NERVE STUDY. ON (B)(6) 2011, THE PATIENT PRESENTED WITH SEVERE PAIN IN LOW BACK AND NECK. ASSESSMENT: ANXIETY. DEPRESSION. CTS. LOW BACK AND NECK PAIN. ON (B)(6) 2011, THE PATIENT WAS ADMITTED TO THE ER DUE TO SKELETAL PAIN FROM THE HARDWARE IN HIS BACK AND NECK. ON (B)(6) 2011, THE PATIENT PRESENTED WITH CHRONIC PAIN AND WRIST PAIN. ASSESSMENT: ANXIETY. DEPRESSION. CTS. CHRONIC PAIN AND WRIST PAIN. ON (B)(6) 2011, THE PATIENT COMPLAINING OF HIGH BACK PAIN. IMPRESSIONS: BACK STRAIN AND CERVICAL MYOFASCIAL STRAIN. THE PATIENT UNDERWENT X-RAYS OF THE CERVICAL SPINE. IMPRESSION: NO EVIDENCE OF ACUTE FRACTURE OR SUBLUXATION. STABLE POST SURGICAL CHANGES. THE PATIENT UNDERWENT X-RAYS OF THE LUMBOSACRAL SPINE. IMPRESSION: NO CHANGE. STABLE PEDICLE SCREW FIXATION AND L3, L4 AND L5. STABLE DISC SURGERY AT L4-5. STABLE L4-5 ANTEROLISTHESIS. NO FRACTURE OR NEW ABNORMALITY. ON (B)(6) 2011, THE PATIENT PRESENTED WITH PERSISTENT LOW BACK AND NECK PAIN. ASSESSMENT: ANXIETY. DEPRESSION. CTS. LOW BACK AND NECK PAIN. BIPOLAR D/O. ON (B)(6) 2011, THE PATIENT PRESENTED COMPLAINING OF UNCONTROLLABLE CRYING SPELLS AND ANXIETY. HE ALSO COMPLAINED OF LACK OF SLEEP. ON (B)(6) 2011, THE PATIENT PRESENTED COMPLAINING OF ARM PAIN. ON (B)(6) 2011, THE PATIENT UNDERWENT X-RAYS OF THE LUMBAR SPINE. FINDINGS: STATUS POST LOWER LUMBAR SPINE FUSION WITH ANATOMICAL ALIGNMENT OF THE LUMBAR VERTEBRAL BODIES. ON (B)(6) 2011, THE PATIENT PRESENTED COMPLAINING OF DEPRESSED MOOD, MOOD INSTABILITY, POOR SLEEP AND ANXIETY. ON (B)(6) 2012, THE PATIENT COMPLAINED OF CRIPPLING NECK AND LOWER BACK PAIN. HE ALSO COMPLAINED OF DEPRESSION, FATIGUE AND NO ENERGY. HE HAS SOME MILD DYSPNEA. ON (B)(6) 2012 ,THE PATIENT WAS CRIPPLED BY NECK AND LOWER BACK PAIN. HE HAS HAD SOME ATYPICAL CHEST PAIN. ON (B)(6) 2012 ,THE PATIENT UNDERWENT MRI OF THE CERVICAL SPINE. IMPRESSION: POST OPERATIVE CHANGES ARE SEEN FOR C4-7. THESE CHANGES DO LIMIT THE EVALUATION DUE TO FAIRLY SIGNIFICANT ARTIFACT. NO ACUTE PROCESSES IDENTIFIED. THE PATIENT UNDERWENT MRI OF THE LUMBAR SPINE. IMPRESSION: FAIRLY EXTENSIVE POST OPERATIVE CHANGES SEEN THROUGHOUT THE MID AND LOWER LUMBAR LEVELS. DORSAL FUSION HARDWARE WITH LONG PEDICLE SCREWS ARE SEEN WHICH DO CAUSE FAIRLY SIGNIFICANT ARTIFACT.. APPEARS TO BE MODERATE BILATERAL EXIT FORAMINAL ENCROACHMENT AT L5 S1 DUE TO DEGENERATIVE CHANGES. A FOCAL DISC HERNIATION IS NOT IDENTIFIED. ON (B)(6) 2012, THE PATIENT PRESENTED FOR LEXISCAN CARDIOLITE HEART SCAN TO ASSESS FOR THE PRESENCE OF ISCHEMIC HEART DISEASE. THE PATIENT HAS HAD ON AND OFF CHEST DISCOMFORT FOR THE LAST SEVERAL MONTHS. CURRENTLY NO OBJECTIVE EVIDENCE OF ISCHEMIA. ON (B)(6) 2012, THE PATIENT UNDERWENT MYOCARDIAL PERFUSION SCAN. IMPRESSION: LEFT VENTRICULAR WALL MOTION IS WITHIN NORMAL LIMITS. LEFT VENTRICULAR EJECTION FRACTION IS 53%. NO DEFINITE PERFUSION DEFECTS ARE IDENTIFIED. THERE IS A VERY SMALL AREA OF RELATIVE DECREASED ACTIVITY WITHIN THE INFERIOR WALL NEAR THE BASE OF THE HEART ON THE STRESS IMAGES WHICH IS NOT SEEN ON THE RESTING IMAGE. IT'S DIFFICULT TO COMPLETELY EXCLUDE POSSIBLY THAT THIS COULD BE A VERY SMALL AREA OF ISCHEMIA BUT ARTIFACT IS SUSPECTED. ON (B)(6) 2012, THE PATIENT PRESENTED WITH CHRONIC NECK AND LOWER BACK PAIN. THE PAIENT'S ATYPICAL CHEST PAIN HAS BEEN RESOLVED. ON (B)(6) 2012, THE PATIENT UNDERWENT X-RAYS OF THE CHEST. IMPRESSION: STABLE CHEST. ON (B)(6) 2012, THE PATIENT PRESENTED WITH THE FOLLOWING PRE-OP DIAGNOSES. THE PATIENT UNDERWENT TOTAL COLONOSCOPY. IMPRESSION: COLON POLYPS. ON (B)(6) 2012, THE PATIENT PRESENTED FOR A MEDICATION FOLLOW-UP. THE PATIENT DISCONTINUED WELLBUTRIN XL AND VISTARIL AS IT CAUSED HIM TO FELL WEIRD. ON (B)(6) 2012, THE PATIENT PRESENTED WITH DEPRESSION AND ATTENTION DEFICIT.
IT WAS REPORTED THAT ON, (B)(6) 2013 THE PATIENT UNDERWENT X RAYS OF THE LUMBAR SPINE SERIES. IMPRESSIONS: NO SIGNIFICANT CHANGES. (B)(6) 2015 THE PATIENT UNDERWENT MRI OF THE LUMBAR SPINE. IMPRESSIONS: STABLE POSTOPERATIVE AND DEGENERATIVE CHANGES.
IT WAS REPORTED THAT ON (B)(6) 2014: THE PATIENT PRESENTED WITH SUBCUTANEOUS ABSCESS. (B)(6) 2014: THE PATIENT PRESENTED FOR FOLLOW-UP CHRONIC PAIN. SYMPTOMS INCLUDES NECK AND BACK PAIN. EGD STUDY WAS NORMAL AND COLONOSCOPY STUDY WAS WITHIN NORMAL LIMITS. (B)(6) 2014: THE PATIENT PRESENTED FOR RECHECK OF FOLLOW-UP FOR CHRONIC CONDITIONS. PATIENT STATED HE FEELS WELL WITH MINOR COMPLAINTS, HAS DECREASED ENERGY LEVEL AND WAS SLEEPING POORLY. (B)(6) 2015: THE PATIENT UNDERWENT MRI OF LUMBAR SPINE WO & W IV CONTRAST AND COMPARED WITH FILM DATED (B)(6) 2013 AND MRI DATED (B)(6) 2012. (B)(6) 2015: THE PATIENT PRESENTED FOR ROUTINE CHECK UP AND MEDICATION REFILLS. PATIENT COMPLAINED ABOUT NAUSEA AND WEAKNESS. EGD STUDY WAS NORMAL AND COLONOSCOPY STUDY WAS WITHIN NORMAL LIMITS. (B)(6) 2015: THE PATIENT PRESENTED FOR ROUTINE CHECK UP AND MEDICATION REFILLS, PATIENT STATED HE IS DOING WELL. ASSESSMENT: CHRONIC BACK PAIN. (B)(6) 2012 THE PATIENT COMPLAINED OF CRIPPLING NECK AND LOWER BACK PAIN. HE ALSO COMPLAINED OF DEPRESSION, FATIGUE AND NO ENERGY. HE HAS SOME MILD DYSPNEA. (B)(6) 2012 THE PATIENT WAS CRIPPLED BY NECK AND LOWER BACK PAIN. HE HAS HAD SOME ATYPICAL CHEST PAIN. (B)(6) 2012 THE PATIENT PRESENTED WITH CHRONIC NECK AND LOWER BACK PAIN. THE PATIENT'S ATYPICAL CHEST PAIN HAS BEEN RESOLVED. (B)(6) 2012 THE PATIENT PRESENTED WITH DEPRESSION AND ATTENTION DEFICIT. (B)(6) 2012: PATIENT PRESENTED FOR FOLLOW UP WITH BACK PAIN. (B)(6) 2012: PATIENT PRESENTED FOR FOLLOW UP WITH THE PROBLEMS OF BACK PAIN, ANXIETY, DEPRESSION AND ADULT ATTENTION DEFICIT DISORDER. (B)(6) 2012: PATIENT PRESENTED WITH DECREASED LIBIDO. PATIENT WAS DISABLED DUE TO CHRONIC BACK PAIN. (B)(6) 2013: PATIENT PRESENTED WITH CHRONIC, DISABLING BACK AND NECK PAIN. PATIENT WAS UNABLE TO WORK. PSYCHIATRICALLY PATIENT WAS DEPRESSED. (B)(6) 2013: PATIENT PRESENTED FOR FOLLOW UP WITH BACK PAIN. BACK PAIN WAS DESCRIBED AS COLICKY. (B)(6) 2013: PATIENT PRESENTED FOR FOLLOW UP WITH BACK PAIN, SEVERE ANXIETY, DEPRESSION AND JOINT PAIN. PATIENT REPORTED SOME SWELLING OF THE LEFT ANKLE. MUSCULOSKELETAL REVIEW REVEALED BACK PAIN, JOINT PAIN, MUSCLE PAIN, CLAUDICATION, AND DECREASED RANGE OF MOTION. PSYCHIATRIC REVIEW REVEALED ANXIETY, DEPRESSION AND INSOMNIA. MUSCULOSKELETAL EXAMINATION REVEALED EXTENSIVE POST SURGICAL CHANGES OVER THE SPINAL COLUMN. THERE WAS SWELLING INVOLVING THE LEFT LATERAL MALLEOLUS. (B)(6) 2013: PATIENT PRESENTED WITH JOINT PAIN, PAIN AND SWELLING IN LEFT ANKLE, ISSUES SEVERE FATIGUE, HYPERSOMNOLENCE AND ERECTILE DIFFICULTIES. MUSCULOSKELETAL REVIEW REVEALED BACK PAIN, JOINT PAIN, MUSCLE PAIN, CLAUDICATION, AND DECREASED RANGE OF MOTION. PSYCHIATRIC REVIEW REVEALED ANXIETY, DEPRESSION AND INSOMNIA. MUSCULOSKELETAL EXAMINATION REVEALED EXTENSIVE POST SURGICAL CHANGES OVER THE SPINAL COLUMN. THERE WAS SWELLING INVOLVING THE LEFT LATERAL MALLEOLUS. (B)(6) 2013: PATIENT PRESENTED WITH JOINT PAIN AND BACK PAIN. MUSCULOSKELETAL REVIEW REVEALED BACK PAIN, JOINT PAIN, MUSCLE PAIN, CLA UDICATION, AND DECREASED RANGE OF MOTION. PSYCHIATRIC REVIEW REVEALED ANXIETY, DEPRESSION AND INSOMNIA. MUSCULOSKELETAL EXAMINATION REVEALED EXTENSIVE POST SURGICAL CHANGES OVER THE SPINAL COLUMN. THERE WAS SWELLING INVOLVING THE LEFT LATERAL MALLEOLUS. (B)(6) 2013: PATIENT PRESENTED WITH EXCESSIVE DAYTIME SOMNOLENCE, SNORING, APNEA, BRUXISM AND RESTLESS LEGS. PATIENT HAD A HISTORY OF MEMORY LOSS, HEADACHES, DEPRESSION, FATIGUE, CHRONIC PAIN, FREQUENT AWAKENING. PATIENT UNDERWENT POLYSOMNOGRAPHY. (B)(6) 2013: PATIENT PRESENTED WITH JOINT PAIN, SEVERE BACK PAIN. PATIENT COMPLAINED OF PAIN DOWN BOTH LEGS AND SEVERE PAIN IN THE LUMBAR AND LOWER THORACIC REGIONS OF THE SPINE. MUSCULOSKELETAL REVIEW REVEALED BACK PAIN, JOINT PAIN, MUSCLE PAIN, CLAUDICATION, AND DECREASED RANGE OF MOTION. PSYCHIATRIC REVIEW REVEALED ANXIETY, DEPRESSION AND INSOMNIA. MUSCULOSKELETAL EXAMINATION REVEALED EXTENSIVE POST SURGICAL CHANGES OVER THE SPINAL COLUMN. THERE WAS SWELLING INVOLVING THE LEFT LATERAL MALLEOLUS. (B)(6) 2013: PATIENT UNDERWENT LUMBOSACRAL SPINE X-RAY DUE TO CHRONIC BACK PAIN AND HISTORY OF PRIOR SURGERY. (B)(6) 2013: PATIENT PRESENTED WITH LOW BACK PAIN. ASSOCIATED DIAGNOSES: ATTENTION DEFICIT DISORDER, CHRONIC BACK PAIN DEPRESSION, LUMBAR DISC DISEASE. MUSCULOSKELETAL REVIEW REVEALED JOINT PAIN, BACK PAIN: BILATERALLY, IN THE UPPER REGION, IN THE MIDDLE OF THE BACK, IN THE LOWER REGION. NECK WAS SUPPLE.
ON (B)(6) 2014 THE PATIENT PRESENTED FOR AN OFFICE VISIT TO HAVE FTX'S AND ESTABLISH NEW PCP. ON (B)(6) 2014 THE PATIENT PRESENTED FOR AN OFFICE VISIT. IMPRESSION: SENSITIVE STAPH AUREUS, PER CULTURE FROM UC. ON (B)(6) 2014 IMPRESSION: SENSITIVE STAPH AUREUS, PER CULTURE FROM UC. JPT CHANGED BY VL TO BACTRIM DS DUE TO DIARRHEA FROM CLINDAMYCIN. (B)(6) 2014; (B)(6) 2014 THE PATIENT PRESENTED FOR AN OFFICE VISIT FOR A ROUTINE CHECK UP. ON AN UNKNOWN DATE 2007: THE PATIENT DIAGNOSED WITH DEGENERATIVE DISK DISEASE, BACK PAIN ON (B)(6) 2008: THE PATIENT UNDERWENT POSTERIOR LUMBAR INTERBODY FUSION ("PLIF") DUE TO NUMBNESS IN LEFT LEG AND LEFT FOOT; SEVERE BACK, NECK, AND SHOULDER PAIN; HEADACHES; DEGENERATIVE DISC DISEASE.SPACER, RH-BMP2/ACS PLUS GRAFT, PEDICLE SCREW, PEEK RODS, AND PEEK CAGE WERE ALSO IMPLANTED. FROM 2007-2008: PATIENT WAS TREATED FOR BACK PAIN. FROM 2008: PATIENT EXPERIENCED POST-OP PAIN. FROM 2008-2013: PATIENT WAS TREATED FOR BACK SURGERY. ON (B)(6) 2008: PATIENT UNDERWENT EGD WITH BIOPSY AND DILATATION. ON (B)(6) 2009: PATIENT UNDERWENT EGD WITH BIOPSY. ON (B)(6) 2009: PATIENT UNDERWENT LAPAROSCOPIC NISSEN FUNDOPLICATION. ON (B)(6) 2009: PATIENT UNDERWENT EGD WITH BIOPSY. FROM 2009/2010: PATIENT WAS TREATED FOR NERVE DAMAGE, DEPRESSION, AND ANXIETY. ON AN UNKNOWN DATE 2010: PATIENT UNDERWENT REMOVAL OF CERVICAL SPINE HARDWARE <(>&<)> FUSION. FROM 2010/2011: PATIENT WAS TREATED FOR GASTROINTESTINAL ISSUES AND PAIN MANAGEMENT. ON (B)(6) 2011: PATIENT UNDERWENT EXTENSIVE MOUTH SURGERY- MOST OF TEETH IN MANDIBLE REMOVED. ON AN UNKNOWN DATE 2011: PATIENT UNDERWENT CARPEL TUNNEL/LEFT HAND SURGERY. ON (B)(6) 2012: PATIENT UNDERWENT TOTAL COLONOSCOPY. ALLEGEDLY, AFTER THE RH-BMP2/ACS SURGERY, INJURIES INCLUDE, BUT ARE NOT LIMITED TO CONSISTENT NECK AND BACK PAIN; SHOULDER PAIN; PAIN RADIATING UP AND DOWN SPINE; MIGRAINE HEADACHES; DIFFICULTY SWALLOWING; DIFFICULTY SPEAKING; HARDWARE FEELS LIKE IT IS COMING LOOSE, CAUSING PAIN AND AFFECTING VOICES; RADIATING PAIN TO THE LEGS; NERVE INJURY; SEXUAL DYSFUNCTION; DEPRESSION; ANXIETY; INABILITY TO LOOK UP OR DOWN; DIFFICULTY.
IT WAS REPORTED THAT THE PATIENT UNDERWENT UNSPECIFIED SURGERY USING RHBMP-2/ACS. REPORTEDLY, THE PATIENT HAS "EXTREME AND EXCRUCIATING PAIN. [PATIENT] MOVEMENT HAS BEEN RESTRICTED SINCE [PATIENT'S] SURGERY."
IT WAS REPORTED THAT ON (B)(6) 2012 THE PATIENT PRESENTED WITH ADENOMATOUS COLON POLYP.
ON (B)(6) 2007: THE PATIENT PRESENTED WITH NECK AND BACK PAIN. IMPRESSION: RIGHT CB RADICULOPATHY; NEUROGENIC CLAUDICATION. ON (B)(6) 2008: THE PATIENT PRESENTED WITH NECK AND RIGHT ARM PAIN. IMPRESSION: CHRONIC NECK AND RIGHT ARM PAIN; CHRONIC BACK AND LEG PAIN. ON (B)(6) 2008: THE PATIENT PRESENTED FOR FOLLOW-UP. PATIENT STATED HE WAS NOT DOING WELL AND HE HAD SEVERE PAIN. DIAGNOSIS; NECK AND ARM PAIN. ON (B)(6) 2008 THE PATIENT PRESENTED WITH PRESENTED WITH A THREE YEAR HISTORY OF PROGRESSIVE NECK AND ARM PAIN, CLINICAL HISTORY OF ACDF AND UNDERWENT LATERAL CERVICAL RADIOGRAPH. EXAMINATION AND MRI SCAN WERE CONSISTENT WITH RIGHT-SIDED RADICULOPATHY. A SINGLE LATERAL INTRA-OPERATIVE MATRIX RADIOGRAPH OF THE CERVICAL SPINE DEMONSTRATES UNREMARKABLE ALIGNMENT DURING ACDF FROM C4 THROUGH C7. 5/06/2008: THE PATIENT PRESENTED WITH COMPLAINT OF NECK PAIN. IMPRESSION: SIX WEEKS STATUS POST CERVICAL FUSION. PATIENT UNDERWENT X -RAY OF CERVICAL SPINE. IMPRESSION: ACDF C4 THROUGH C7. ALIGNMENT APPEARS TO BE ANATOMIC. ON (B)(6) 2008: THE PATIENT PRESENTED WITH NECK PAIN. IMPRESSION: THREE MONTHS STATUS POST THREE LEVEL CERVICAL FUSION. THE PATIENT UNDERWENT X-RAY OF CERVICAL SPINE FLEXION/EXTENSION VIEWS OF THE CERVICAL SPINE DEMONSTRATE POSTSURGICAL CHANGE STATUS POST ACDF C4-C7. STABLE ALIGNMENT. NEGATIVE FOR DYNAMIC INSTABILITY WITH LIMITED RANGE OF MOTION NOTED. ON (B)(6) 2008: THE PATIENT PRESENTED WITH NECK AND BACK PAIN. IMPRESSION: CHRONIC BACK PAIN.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 65082 | INFUSE BONE GRAFT | FILLER, RECOMBINANT HUMAN BONE MORPHOGENETIC PROTEIN, COLLAGEN SCAFFOLD WITH MET | NEK | MEDTRONIC SOFAMOR DANEK USA, INC | NA | M110708AAC |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | Required Intervention |