RE: Mr.

John does
Date of Birth: January 01, 1000
Employer: City of Utopia
Date of Injury: March 26, 2018

Approximately 280 pages of records have been received and reviewed by the
undersigned. Documents within the records, which are not considered of medical
importance to this practitioner, may not be included in the summary though they have
been reviewed in their entirety.

REVIEW OF FILE

Cover Letter, signed by Justin A. Williams, Law Offices of Parente & Christopher,
dated January 5, 2019.

This examiner agreed to evaluate the applicant in the capacity of Panel Qualified Medical
Examiner. The applicant is scheduled to be evaluated by him in his office on February
13, 2019 at 12:30 p.m. Please be advised that this office represents the City of
Pleasanton and Innovative Claim Solutions.

This claim involves a xxxxx. The applicant was injured on March 26, 2018. At that
time, he was walking through a home when he fell through a hole in the floor and
dropped approximately 3 feet. The applicant immediately reported injuries to the knee
and low back. The applicant was seen in the emergency room and taken off of work. He
had not returned to work since that time.

The applicant is also alleging a cumulative trauma running through August 9, 2018. This
claim has been disputed. The applicant alleges injuries to the spine, bilateral knees,
bilateral shoulders, bilateral upper extremities and right elbow. This claim was placed on
delay for lack of medical evidence, before eventually being denied on the same grounds.
Nevertheless, we are asking that you evaluate the legitimacy and merits of this claim.

In addition to the above, the applicant has alleged a claim of injury resulting from a
cumulative trauma through January 5, 2018. He alleges injuries to the brain and
circulatory system. The applicant was evaluated for that claim by Dr. Ansel, who found
no industrial injury. As such, that claim has been denied. You are not being retained to
evaluate that injury.

Of significance, and with regard to the low back, is the applicant’s history of prior
injuries and awards for permanent disability. The applicant initially sustained a low back
injury on July 5, 2002. That claim was accepted, and the applicant received an award
from the WCAB for permanent disability. The applicant sustained at least one additional
low back injury that occurred on September 18, 2017. Again, he litigated this claim and
Lima, Christopher

was given an award for 14% permanent disability. Obviously, both of these prior injuries
would need to be considered and addressed for purposes of apportionment.

Accordingly, following your review of the enclosed records, and your usual and thorough
evaluation of the applicant, we would appreciate your opinions and diagnoses regarding
his various complaints.

Please indicate whether or not in your opinion, the applicant’s injuries were directly
caused by his employment as a Fire Captain. If so, please identify the specific cause of
injury and its mechanism. We would further ask that you specifically identify the nature
and extent of the applicant’s injuries, if any, and clearly identify each body part that is or
is not compensable as an industrial injury.

Please indicate whether or not the applicant is permanent, stationary, and ratable as of the
date of your examination. If so, please indicate when he reached that status. If not,
please indicate when he will reach that status.

If you find him to be permanent and stationary, please set forth the subjective and
objective factors of disability, together with the work preclusions or limitations, if any.
Please identify the applicant’s ratable impairment, if any, using the AMA Guides, Fifth
Edition.

Please indicate whether you would apportion the applicant’s disability and/or
impairment, if any, to non-industrial and/or pre-existing and/or subsequent factors,
including any condition that may have been present, even if asymptomatic, as of the date
of your examination even absent the industrial injury herein.

Please indicate whether or not the applicant is in need of additional medical treatment on
an industrial basis. If so, please set forth the specific modalities of treatment that may be
necessary in the future and estimate the duration and frequency of those treatments.

Please indicate whether or not the applicant is capable of returning to his former position
as a Fire Captain, either with or without restrictions.

Applicant’s attorney may have additional questions for you to answer. Please answer
those questions as well as the ones posed above.

(.pdf_Pages 1-4)

MEDICAL RECORDS:
Lima, Christopher

Emergency Department Report, signed by Michael Costello, M.D., Emergency

Medicine, Jenna Musgrove, R.N., Stanford Health Care ValleyCare Emergency
Department, dated January 5, 2018.

History of Present Illness: The applicant presented to Emergency Room with sudden
onset of blurred vision that lasted 10-15 seconds. He was a firefighter and had onset of
blurred vision more precisely described as double vision lasting several seconds while he
was sitting at table at the station. He was not feeling right since the onset of symptoms.

Past Surgical History: He underwent tonsillectomy and surgery for tibia and fibula
fracture.

Allergies: He is allergic to Penicillin, Sulfa drugs and Tetracycline.

Medications: He was taking Zanaflex as needed and Mobic twice a day.

Laboratory Data: Basic Metabolic Panel showed elevated levels of BUN at 27 mg/dL
and eGFR was low at 79 mL/min. CBC was within normal limits. Pro-thrombin time
and partial thromboplastin time was within normal limits.

CT scan of the head without contrast and CT scan of the head and neck with IV contrast
were ordered, performed and reviewed.

Diagnosis: Visual disturbance.

Treatment Rendered: Normal saline IV 500 mL bolus and Normal Saline IV 150 ml/hour
were administered.

Plan: He was referred to neurologist for re-check. He was advised to re-check with
Occupational Health Medicine on January 7, 2018.

Disposition: He was discharged to home in satisfactory condition.

Work Status: The applicant was placed on modified duty from January 5, 2018 through
January 8, 2018 with restrictions of limited lifting up to 25 pounds or less and sitting,
walking, standing, bending, squatting, climbing and kneeling as tolerated.

(.pdf_Pages 213, 225, 237, 239, 241, 243, 245, 247, 249, 251, 253, 255, 257, 259, 261)

Doctor’s First Report of Occupational Injury or Illness, Illegible Signature, dated

January 5, 2018.

Date of Injury: January 5, 2018.

Lima, Christopher

Subjective Complaints: The applicant complained of double vision for 20 seconds, and
fatigue.

Diagnosis: Frequent visual disturbances.

Plan: Labs and CT of the head and neck were ordered. He was referred to neurologist.

Work Status: He was placed on modified work from January 6, 2018 and light duty for 3
days.

(The rest of the report is illegible).

(.pdf_Pages 263)

CT of the Brain without contrast, signed by Patrick Ryan, M.D., Radiologist,

ValleyCare Health System Diagnostic Imaging Services, dated January 5, 2018.

Impression: No acute intracranial process.

(.pdf_Pages 215-217)

CT of the Head and Neck with IV contrast, signed by Patrick Ryan, M.D.,
Radiologist, Valley care Health System, dated January 5, 2018.

Impression: 1) CTA of the neck demonstrated no evidence of hemodynamically

significant stenosis and no ulcerated plaque. 2) CTA of the head demonstrated no
evidence of hemodynamically significant stenosis or aneurysm. 3) There was mild
multilevel degenerative disc disease. 4) There was re-demonstrated mucosal thickening
of the maxillary sinuses as well as the ethmoid air cells, with air-fluid level in left
maxillary sinus, and complete opacification of selected ethmoid air cells.

(.pdf_Pages 219-221)

Doctor’s First Report of Occupational Injury or Illness, signed by Wesley Chan,

M.D., Occupational Medicine, Stanford Health Care ValleyCare Occupational
Health Service, dated January 9, 2018.

Date of Injury: January 5, 2018.

Subjective Complaints: The applicant presented for Emergency Room re-check for his
vision problem. He had one episode of spontaneous double vision.
Lima, Christopher

He was a fire captain for Livermore Pleasanton Fire Department and on January 5, while
sitting and talking at the firehouse kitchen, he had spontaneous double vision. He stated
that it was a weird depth perception distortion that lasted for about 10-15 seconds. The
incident only happened once. He was off work since the incident. He had no complaints
at this time.

Allergies: He was allergic to Sulfa, Tetracycline, and Penicillin.

Medications: He was taking Mobic daily, Zanaflex daily, Acyclovir, Flonase, and anti-
histamine.

Problem List: He had seasonal allergies and back injury.

Diagnosis: Diplopia.

Plan: He was advised to follow up in 1-2 weeks. His follow-up appointment was
scheduled on January 25, 2018.

Work Status: He was advised to return to regular work on January 9, 2018.

(.pdf_Pages 191, 193, 195, 196, 197, 199, 201)

Progress Note, signed by Wesley Chan, M.D., Occupational Medicine, Stanford

Health Care ValleyCare Occupational Health, dated January 25, 2018.

Date of Injury: January 5, 2018

Subjective Complaints: Since last visit, the applicant’s symptoms were overall a little bit
better. He was currently on regular duty. Light duty was not provided by the employer.
He presented for recheck of blurred vision . He denied double vision at present, but still
had blurred vision. He had seen eye doctor and distant glasses was recommended. He
complained of lightheadedness.

He had a recent viral upper respiratory infection a couple of weeks ago.

Medications: He was taking Mobic, Zanaflex, Acyclovir, Flonase and anti-histamine.

Assessment: Diplopia.

Plan: A qualified neurologist consultation was requested. A follow-up appointment was

scheduled on February 28, 2018.

Work Status: He was to remain on regular duty from January 25, 2018.
Lima, Christopher

(.pdf_Pages 181, 183, 185, 187-190)

Primary Treating Physician’s Progress Report (PR-2), signed by Wesley Chan,

M.D., Occupational Medicine, Stanford Health Care ValleyCare Occupational
Health Services, dated March 7, 2018.

Date of Injury: January 5, 2018

Subjective Complaints: The applicant presented here for recheck of double vision. He
stated that his vision was fine. He had no reoccurrence and was feeling good. He had not
seen a neurologist, wondering if he still should.

Medications: He was taking Mobic daily, Zanaflex daily, Acyclovir, Flonase, and anti-
histamine.

Diagnosis: Diplopia.

Treatment Plan: Neurology consultation was cancelled.

Work Status: He was discharged to regular work on March 7, 2018.

(.pdf_Pages 169, 171, 173, 175, 177, 179)

Emergency Department Provider Note, signed by Andreas Tjoe, M.D., Emergency

Medicine, Stanford Health Care ValleyCare, dated March 26, 2018.

History of Present Illness: The applicant presented with back injury as he fell through the
floor. He was a fireman and was walking through the house where they had made a hole
in the first floor. He did not realize it and fell through the hole about 3 feet down onto
the ground and landed on his feet. Since then, he had pain to the left knee and lower back
and this happened that evening. He had not taken any pain medication prior to arrival.
He had no other injuries.

Allergies: He was allergic to sulfa drugs.

Medications: He was taking Acyclovir 400 mg and Omeprazole 20 mg.

Past Surgical History: He underwent sinus balloon dilation endoscopy.

Past Medical History: He has a history of back pain.

Lima, Christopher

Physical Examination: He seemed to have paravertebral tenderness to the lower back

bilaterally.

X-rays of the lumbar spine and left knee were obtained and were negative for acute
fracture.

Diagnoses: 1) Acute bilateral low back pain without sciatica. 2) Knee injury, left.

Emergency Department Treatment: Ibuprofen 600 mg and Cyclobenzaprine 10 mg were

given.

Plan: Cyclobenzaprine 10 mg and Ibuprofen 600 mg were prescribed. He was advised to

follow-up with ValleyCare Occupational Health on March 28, 2018.

Disposition: He was discharged home in stable condition.

(.pdf_Pages 35-40)

Work Status Form, signed by Andreas Tjoe, M.D., dated March 27, 2018.

The applicant was placed on modified duty from March 27, 2018 to March 29, 2018 with
restrictions of lifting less than 5 pounds, driving restrictions and cannot work for 4
consecutive hours or more in a day. He was advised to rest his back and knee. The
applicant might return to work on March 30, 2018.

(.pdf_Page 22,47)

X-ray of the Lumbar Spine, signed by Andrew Kesselman, M.D., radiologist, VCP
Diagnostic Radiology, dated March 27, 2018.

Impression: No acute bony or articular abnormality.

(.pdf_Pages 20-21)

Doctor’s First Report of Occupational Injury or Illness, signed by Walter

Panganiban, M.D., Family Medicine, dated March 30, 2018.

Date of Injury: March 26, 2018.

Present Complaint: The applicant presented with low back injury and sprain/strain. He
complained of constant, aching, dull and sharp lower back pain and spasm and pain was
rated as 3/10.
Lima, Christopher

Mechanism of Injury: He was a firefighter and sustained a fall injury that happened
when he was responding to a fire. They had cut a hole in the floor and he ended up
walking and fell into a 3 feet hole. The impact had caused pain in lower back and felt a
twinge in his left knee. He went to Pleasanton Emergency Room where they did x-rays
of his left knee and back, which were negative. He took Advil for pain with minimal
effect. His pain level increased up to 7/10 with activity. He had low back pain that was a
dull ache with occasional sharp spasms and low back pain was mostly on his right side.
He complained of low back pain and left knee pain. Compared to when it happened, the
left knee pain was improving.

Allergies: He is allergic to Sulfa.

Medications: He was taking Advil.

Past Medical History: He had a history of back injury and sinus surgery.

Objective Findings: The low back was feeling stiff and worsened on the left side. He
had low back tenderness and spasm over left paraspinal muscles. Range of motion was
limited.

Diagnosis: Strain of muscle, fascia and tendon of lower back.

Work Status: He was temporarily off work until further evaluation.

(.pdf_Pages 51-55)

Progress Note, signed by Walter Panganiban, M.D., Family Medicine, Stanford

Health Care ValleyCare Occupational Health Services, dated April 5, 2018.

Date of Injury: March 26, 2018

Subjective Complaints: Since last visit, his symptoms were overall a little worse and
current pain level was rated as 5/10. He was currently off work. Light duty was not
provided by the employer.

He presented here for re-check of low back pain. He still had pain and was very tight in
the morning and it took a few hours to loosen up. He was trying to walk and stretch, but
was feeling that he had to be very careful. He was trying a Tens unit at home and was
taking Motrin as needed.
Lima, Christopher

He was involved in an industrial injury in September 18, 2017. He had a back injury and
was initially treated at Kaiser Occupational Health and received physical therapy. He
was then transferred to Dr. Grant. MRI of the lumbar spine was performed and showed
multilevel disc disease with disc bulges and a large disc herniation at L4-L5. Dr. Grant
did not feel that he was a surgical candidate. He was released to full duty sometime in
December. He was still in pain and continued to be in pain at the time of this current
incident. He had occasional leg pain.

Diagnosis: Strain of muscle, fascia and tendon of lower back, condition was worsening.

This was an exacerbation of previous industrial injury dated September 18, 2017.

Treatment Plan: Physical therapy twice a week for three weeks was recommended.
Urgent transfer of care to a qualified spine specialist was requested and he was already
authorized to be seen by Dr. Grant. He was recommended to follow up in 7 days and he
could cancel follow-up if seen by Dr. Grant.

(.pdf_Pages 125-128)

Progress Note, signed by Wesley Chan, M.D., Occupational Medicine, Stanford

Health Care ValleyCare Occupational Health Services, dated April 13, 2018.

Date of Injury: March 26, 2018

Subjective Complaints: The applicant presented here for lumbar strain. His symptoms
since last visit was overall unchanged. He rated his pain as 5/10. He was currently off
work. Light duty was not provided by the employer. Therapy was ordered, but had not
started yet. Since last visit, he was using the same amount of medication. He still had
pain with limited mobility. He tried to do ADLs, but had pain and had to stop. He was
frustrated with lack of progress, and still had not seen Ortho yet with Dr. Grant. He
would start physical therapy next week. His main symptom was a band of pain across the
low back.

Physical Examination: He had tenderness at L4-L5 along paraspinous musculature and

facets, and painful range of motion.

Assessment: Other intervertebral disc displacement, lumbosacral region.

Treatment Plan: Transfer of care to a qualified PM&R specialist to consider injection

was requested. Previous order for transfer of care to Dr. Grant was cancelled.

Work Status: He was temporarily off work as of March 30, 2018.

Lima, Christopher

(.pdf_Pages 120-123)

Physical Therapy Initial Evaluation, signed by Jasmine Mehta, P.T., Select Physical
Therapy, dated April 18, 2018.

Date of Injury: March 26, 2018

Diagnosis: Low back pain.

History of Injury: The applicant’s history of back pain was exacerbated when he fell
through the hole in floor while at work. Pain was unchanged since 1 year, but felt his
stiffness was worsened since 1 year. Symptoms were at back, but went to right buttock.
He was not a candidate for surgery due to extensive degenerative changes. He was off
work since few months as he was not able to tolerate sitting in modified work. He was
unable to work secondary to dysfunction. He felt that he always gets up crooked to the
right side. Pain was worse in the morning, rated as 2-8/10.

Functional Comorbidity Index: Arthritis (RA, OA). Degenerative disc disease.

Rehabilitation Goals: Minimize pain and loss of motion or stiffness.

Objective Findings: He was currently not at working limits and was lifting less than 5
pounds. Range of motion of the lumbosacral spine was decreased.

Treatment: Manual therapy techniques, neuromuscular reeducation, therapeutic

activities, therapeutic procedure and stabilization training were provided.

Assessment: He required skilled physical therapy to address the problems identified and
to achieve the individualized applicant goals as outlined in the problems and goals
section of the evaluation. Overall rehabilitation potential was fair. He presented with
chronic pain, had major limitation with extension ROM. He might need more therapy to
improve functions and ROM.

Recommendations: Skilled intervention was required to decrease pain, improve function,

increase range of motion and increase strength.

Goals: Goals were to decrease pain by centralizing radicular symptoms, increase strength
to 5/5 and range of motion of lumbosacral spine to 50%.

Plan: He was recommended to attend rehabilitative therapy for 2 visits a week for 6
weeks. Therapeutic contents included active range of motion activities, home exercise
program, joint mobilization techniques, manual range of motion activities. Pro-
prioceptive/closed kinetic chain activities, therapeutic activities, therapeutic exercise,
stretching/flexibility activities.
Lima, Christopher

(.pdf_Pages 118-119)

Progress Note, signed by Wesley Chan, M.D., Occupational Medicine, Stanford

Health Care ValleyCare Occupational Health, dated April 25, 2018.

Date of Injury: March 26, 2018

Subjective Complaints: Since last visit, symptoms were overall unchanged. He rated his
current pain level at rest and activity as 4/10. He was currently off work. He was
attending physical therapy and had completed 3 sessions. He was using the same amount
of medications. MRI was done at Kaiser. He had an appointment to see Dr. Rhee, Spine
Institute on May 7, 2018. Records from Kaiser were reviewed.

MRI of the lumbar spine from September 26, 2017 showed L4-5 left paracentral disc
protrusion with stenosis of the right lateral recess.

Objective: Back with tenderness at L4-L5 along paraspinous musculature and facets. He
had painful range of motion.

Diagnoses: 1) Strain of muscle, fascia and tendon of lower back. 2) Other intervertebral
disc displacement, lumbosacral region.

Plan: MRI of the lumbar spine was ordered. His care was transferred to Dr. Rhee.

Work Status: The applicant was placed on temporary disability from April 25, 2018.

(.pdf_Pages 106, 110, 112-113)

Physical Therapy Progress Note, signed by Jasmine Mehta, P.T., Select Physical
Therapy, dated April 25, 2018.

Diagnosis: Low back pain.

Subjective Complaints: The applicant’s MRI showed foramen stenosis at L3-5 and he
stated that he was not a candidate for surgery due to extensive degenerative changes.
Currently, he was unable to work secondary to dysfunction. He felt that he always gets
up crooked to the right side. Pain was worsened in the morning, rated as 2-8/10. He felt
a little looser with exercises. He had some pain in the right buttock and some pain on the
left side as well. He walked for 2 miles and his pain was getting worse after walking.

Objective Findings: He had decreased strength and range of motion.

Lima, Christopher

Assessment: He tolerated treatment intervention with minimal complaints of pain. He

felt no pain after the therapy that day. His range of motion in extension improved with
exercises.

Plan: He was advised to continue with current rehabilitation program and advance as
tolerated.

(.pdf_Pages 114-115)

Initial Visit Note, signed by James Rhee, M.D., Physical Medicine and
Rehabilitation, Northern California Spine Institute, dated May 7, 2018.

Date of Injury: March 26, 2018

History of Present Illness: The applicant was seen with complaints of chronic low back
pain that referred down the right leg. He was having low back pain with sciatica episodes
over the years. He apparently saw Dr. Grant initially in 2003 for a 2003 claim and saw
him again last year for another claim. He was able to recover fairly well, although he
continued to be somewhat symptomatic for his lower back. On March 26, 2018, he fell
in a hole while on a fire call where he landed on his feet, which jarred his back and then
flaring up his symptoms. He had 4 sessions of physical therapy in Hayward. He noted
that on one occasion, the therapist was working on his lower back and he had a weird
tingling down the back of the right leg, so they decided to stop therapy. He had done
some prior core strengthening. Currently, he was in constant misery, although he was
scheduled for a lumbar spine MRI the next day. He would like to improve his condition
back to a baseline state.

Subjective Complaints: He described as stabbing, aching, and burning sensations across

the lower back bilaterally, a bit more on the right side compared to the left. He had
numbness that goes down the back of the right leg with tingling that comes and goes, but
not below the knee level. He would get some pins and needles sensations in the sole of
the right foot. He noted significant morning symptoms where it might take him a couple
of hours to get going. His symptoms were provoked with sitting as well as lying down
prone.

Medications: He was taking Acyclovir, Loratadine, Ibuprofen 800 mg and Aleve. He

noted that Flexeril made him moody, but the Zanaflex was tolerated in the past.

Allergies: He is allergic to Sulfa.

Social History: He drinks alcohol frequently.

Past Medical History: He has a history of sinusitis, environmental allergies, and herpes.
Lima, Christopher

Physical Examination: He had extreme tightness across the lumbar paraspinals,

predominantly on the right side that goes into the mid back area, although most of his
pain was confined to the right lower back and he had lesser degree on the left side. He
noted that he was quite guarded with his back lately. He had a little bit of sensitivity in
the right buttock. Lumbar flexion was almost horizontal whereas extension was quite
minimal with right low back pain. He reported numbness in the right posterior thigh to
the knee level, but not distally, nor on the left side. Again, it extended sporadically into
the sole of the right foot. His gait was guarded with some stiffness, but no obvious
asymmetry, but with some low back pain. Right-seated dural stretch caused symptom
irritation down the right thigh whereas left side testing was unremarkable.

Impression: 1) Chronic recurrent low back pain in a broad pattern, slightly more along
the right side, but with some numbness along the right posterior thigh and stabbing
sensations in the right heel. He was scheduled for another lumbar spine MRI tomorrow.
Exam today demonstrated some pelvic girdle weakness, predominantly on the right side,
with nerve tension signs. 2) Chronic history of low back pain episodes going back to
2003.

Plan: He was scheduled for another MRI of the lumbar spine the next day. A trial of
spine stabilization exercise for long-term goals was suggested. Zanaflex was refilled.
Right-sided lumbar epidural steroid injection targeting the L4-5 level was discussed. He
could follow-up with Dr. Grant for surgical options.

Work Status: He indicated being off work entirely and would be continued on this for the
next 15 days until the applicant follows up with a new MRI scan.

(.pdf_Pages 92-96, 102)

MRI of the Lumbar Spine without contrast, signed by Philip Chyu, M.D.,
Radiologist, Pleasanton Imaging Center, dated May 8, 2018.

Referring Physician: Wesley Chan, M.D.

Clinical Indication: Low back strain.

Impression: 1) Small broad-based and left paracentral disc protrusion at L1-2 with
moderate left and mild right foraminal narrowing. 2) Moderate left and mild right
foraminal narrowing at L2-3 with a small broad-based disc protrusion. 3) Severe left and
moderate right foraminal narrowing at L3-4 with facet joint arthropathy and broad-based
disc protrusion. 4) Mild central spinal canal with moderate bilateral foraminal narrowing
at L4-5 with facet joint arthropathy, broad-based and right paracentral disc protrusion. 5)
Mild facet joint arthropathy with a small central disc protrusion at L5-S1.
Lima, Christopher

(.pdf_Pages 90-91)

Physical Therapy Re-Evaluation, signed by Jasmine Mehta, P.T., Physical

Therapist, Select Physical Therapy, dated May 18, 2018.

History of Injury: The applicant had history of intermittent back pain that exacerbated
when he fell through the hole in floor during work. His back pain was unchanging since
two years and was limited to back and right buttock area, but recently was feeling pain
radiating to his right side and was staying above the knee. His sitting tolerance was less
than 5 minutes and he was better with walking and could walk greater than 30 minutes.
He had physical therapy in the past and had no relief with manual, core strengthening or
modalities.

Subjective Complaints: His back pain was radiated to the right buttock area. His pain
was worse in the morning and he was feeling that he was always waking up with a right
side list that gradually getting a little better with movement. He complained of
intermittent pain radiating from back to right thigh. He rated his pain current at 6/10, best
at 2/10 and worst at 8/10. He was unable to tolerate pelvic tilts in supine, felt some sharp
pain and had to walk to reduce his pain.

Work Status: He was unable to work secondary to dysfunction.

Objective Findings: Lumbosacral extension was 10%, flexion 70%, side glide left 50%
and right 50%. He had decreased strength and range of motion.

Treatments: Therapy included neuromuscular reeducation, therapeutic activities,

stabilization training in sitting and prone position and exercise activities.

Recommendations: He was not able to tolerate reductive exercises tried for him, pain
starts peri-pharalising with it, and neutral spine exercises demonstrated poor tolerance.
He did not show any objective improvement post-therapy. He had modalities in the past
and they had not helped him to reduce pain in the past. At this point, the applicant was to
consult his doctor and work out alternatives that could help him to tolerate therapy to
address his symptoms.

Goals: Goals included decreasing pain by centralizing radicular symptoms, improvement

in range of motion and improvement with extension up to 50%.

Plan: Therapeutic contents included home exercise program, active range of motion
activities, and manual therapy techniques. He was advised to recheck after doctor’s visit.
Lima, Christopher

(.pdf_Pages 88-89)

Physical Therapy Sessions, signed by Jasmine Mehta, P.T., Physical Therapist,

Select Physical Therapy, dated April 18, 2018 to May 18, 2018.

The applicant had completed 5 sessions of physical therapy for low back pain from April
18, 2018 to May 18, 2018.

On May 18, 2018, he rated his pain as 6/10, best at 2/10, worst at 8/10. He was not able
to tolerate reductive exercises tried for him, pain starts peripheralizing with it. Neutral
spine exercises also demonstrated poor tolerance. He did not showed any objective
improvement post-therapy. He mentioned that he had modalities in the past and they did
not helped him to reduce pain in the past. He would consult his doctor and work out
alternatives that could help him to tolerate therapy to address his symptoms.

(.pdf_Pages 88-89, 103-104, 114-115, 116-117, 118-119)

Primary Treating Physician's Progress Report (PR-2), signed by James Rhee, M.D.,
Physical Medicine and Rehabilitation, Northern California Spine Institute, dated
May 23, 2018.

Current Progress: The applicant stated that his condition was worsening. He felt like he
was taking 1 step forward and 3 steps back. He was having physical therapy at Select
Physical Therapy in Hayward, but because of lack of progress, his therapist had
recommended that he pursue medical intervention, that is LESI. He noted stabbing and
electric shock-like sensations that go down into the back of the right leg into his heel. He
was not working at this time. He noted having tried oral steroids last year for another
back problem without benefit, but was causing some insomnia.

Physical Examination: He had tenderness across the right lower back extending into the
right buttock. Lumbar flexion range of motion was with mild restrictions whereas
extension caused right sciatica. He was constantly moving during the visit that day. He
had right L5-S1 pattern numbness. Gait was with stiffness as he was guarding with
movement. Right seated dural stretch caused symptom provocation down the right thigh
whereas left side testing was unremarkable.

Impression: 1) Persistent worsening right sciatica, likely due to right L4-5 paracentral
disc protrusion. He was trying physical therapy, but without progress. 2) Chronic history
of low back pain episodes going back to 2003.

Plan: A trial of Toradol 10 mg was suggested with potential adverse effects reviewed
given his lack of response with steroids previously. Fluoroscopic-guided right-sided
epidural steroid injection was re-discussed and the applicant consented to submit a
Lima, Christopher

request for right L5-S1 TFESI. Follow-up in several weeks after the procedure was
advised.

Work Status: He was to continue TTD status for the next 45 days.

(.pdf_Pages 82-87)

Panel Qualified Medical Examination, signed by Robert Ansel, M.D., Neurologist,

dated June 18, 2018.

Date of Injury: January 5, 2018.

History: The applicant was a firefighter for the City of Livermore and Pleasanton for 27
years. He had the typical duties of a firefighter, both administrative and actually fighting
fires. His episode occurred on January 5, 2018, while in the firehouse. He had finished
dinner, acknowledging that there was nothing unusual during that day.

He stated that all of a sudden he saw double. There were no additional symptoms at that
time. Vision was side-by-side and it lasted about 15 seconds. He was unable to change
the double vision as he looked up, down and around.

He stated that he felt funny. This was a very non-specific symptom. He went to the
emergency room and as he had a rather extensive series of imaging studies, all of which
reported normal.

Unfortunately, he had a second episode several weeks later. This was similar to that
noted before and it lasted somewhat longer.

Past Medical History: He had some back issues on a work basis, and was off work since
March of 2018. He reported that cortisone was pending. He had undergone sinus
surgery.

Medications: He takes a variety of medication for his back, anti-inflammatory as well as

medication for seasonal allergies.

Work History: He had not missed work other than a day or two as a result of the above in
January of 2018 and as noted, had done his usual job save for his temporary disability
secondary to his back.

Social History: He drinks alcohol occasionally.

Physical Examination: He had some generalized back discomfort.

Lima, Christopher

Discussion: He was neurologically intact and from a neurologic standpoint and had
continued to work, but unfortunately was off work secondary to another injury from his
lumbar spine. The issue was emanating from his brainstem and since it had resolved, it
would be a transient ischemic attack. The applicant would discuss taking a Baby Aspirin
on a prophylactic basis with his PCP. He had no permanent disability or work
impairment from a neurologic standpoint. However, it was suggested that there was a
remote possibility that this might recur again and as such was suggested that he take a
Baby Aspirin on a prophylactic basis.

Work Status: The applicant could return to regular work.

(.pdf_Pages 131,133, 135,137, 139, 141, 143)

Procedure Report, signed by James Rhee, M.D., Physical Medicine and

Rehabilitation, Hacienda Surgery Center, dated June 22, 2018.

Pre/Post-Operative Diagnosis: Right lumbar radiculopathy.

Procedure Performed: 1) Right L5-S1 interlaminar epidural steroid injection. 2) Aborted

right L5-S1 transforaminal epidural steroid injection. 3) Fluoroscopy. 4) Conscious
sedation.

Post-procedure instructions were given to the applicant. He was advised to apply an ice
pack to the area should a pseudo-flare-up occur.

(.pdf_Pages 79-81)

Primary Treating Physician's Progress Report (PR-2), signed by James Rhee, M.D.,
Physical Medicine and Rehabilitation, Northern California Spine Institute, dated
July 5, 2018.

Date of Injury: March 26, 2018.

Current Progress: The applicant returned for follow-up after undergoing a right L5-S1
interlaminar ESI on June 22, 2018. Dr. Rhee attempted a right L5-S1 TFESI, but he had
pain/pressure provocation down the right leg, so he aborted that. At that point, he
indicated that the epidural injection seemed to help to some degree for his leg condition,
but not so much for his lower back at all. He denied any adverse effects. The lower back
was his primary complaint. He noted that it was a hassle to get his Toradol prescription,
so he was using it sparingly. He got some relief with that as well. He noted limited sleep
where he had to take some Percocet the previous night, even though he was normally
against taking opioids. He did not have any spiking pain like before, but he had a strange
pain in his right thigh last night. He felt like his back was really bound up.
Lima, Christopher

Physical Examination: He has palpable tenderness across the lower back bilaterally.
Lumbar flexion was with mild restrictions whereas extension was quite minimal with
right sciatica pain issues. He reported paresthesias down the right leg into the outer foot,
which seemed to be consistent with an S1 pattern. Gait appeared to be good, but with
some stiffness. Right seated dural stretch caused symptom provocation down the right
thigh whereas left side testing was unremarkable.

Impression: 1) Right sciatica, likely due to right L4-5 paracentral disc protrusion where
he had some improvement of his right leg pain and better ankle strength, but he was still
having significant low back pain after a recent LESI. He had advanced multilevel
spondylosis with severe loss of disc height at multiple levels along with a right L4-5
paracentral disc protrusion with lateral recess stenosis. He also had moderate-to-severe
right L4-5 and L5-S1 foraminal stenosis. 2) Chronic history of low back pain episodes
going back to 2003.

Plan: A trial Duloxetine starting at 20 mg and then up titrate it weekly to a maximum of

60 mg daily was recommended. He was advised to continue home exercise program ad-
lib. Follow up with Dr. Grant for surgical options was discussed. Follow-up within the
next 45 days for non-surgical management was advised.

Work Status: He was advised to continue temporary totally disability status for the next
45 days.

(.pdf_Pages 74, 76-78)

Injury and Illness Work Status Form, signed by James Rhee, M.D., Physical
Medicine and Rehabilitation, Northern California Spine Institute, dated July 16,
2018.

The applicant was placed on temporary disability from July 5, 2018 to August 19, 2018.
His next appointment was scheduled on July 23, 2018.

(.pdf_Page 75)

Visit Note, Unsigned, Northern California Spine Institute, dated July 23, 2018.

Date of Injury: March 26, 2018

History of Present Injury: The applicant presented that day with a new workers
compensation claim. He had previous injuries to his back at work. He did work as a fire
captain. He was doing fairly well and was at work on March 26, 2018 and during a fire,
he ended up falling and fell a few feet, wearing all of his gear, jarring his back. He had
Lima, Christopher

sudden onset of pain in his back and developed some pain radiating to his right lower
extremity, which had persisted since that time. His pain was somewhat up and down;
however, at that point, it was the worst it had been over the past few months. He
described pain in the distal lumbar region and surrounding paraspinal musculature that
was increased with standing and extending at the lumbar spine. He described some
dysesthesias in the right buttock, posterior thigh, and calf as well as somewhat in the
lateral thigh and calf at times. His back pain was much greater than his leg symptoms.
He did undergo some physical therapy; however, this was only exacerbating his
symptoms and therefore was discontinued. He also recently underwent an epidural
injection at L5-S1, translaminar approach, with Dr. Rhee, which, unfortunately, had
provided no relief of his pain. He was currently taking Ibuprofen as needed for pain
relief and was recently started on Cymbalta as well, which had not been of any benefit for
him thus far. He was currently on TTD and he had no other current complaints.

Present Medications: He was taking Acyclovir 400 mg, Loratadine 10 mg and Ibuprofen
800 mg.

Allergies: He is allergic to Sulfa.

Past Medical History: He has a history of sinusitis and history of herpes.

Past Surgical History: He underwent endoscopic sinus surgery in February 2018.

Physical Examination: He ambulated with a stable and steady gait. He overall

demonstrates good posture. He had pain localized in the distal lumbar region and
surrounding paraspinal musculature without focal tenderness. He did have significant
increased pain with limitation in lumbar extension. He had pain with forward flexion.
There was 5/5 strength in all muscle groups in both lower extremities. He had mildly
positive right straight leg raising test.

Impression: 1) Lumbago with multilevel lumbar degenerative disc disease and facet
arthrosis. 2) Right L4-5 disc herniation with mild lower extremity radiculopathy.

Discussion: The epidural provided minimal relief of any of his symptoms. He was not a
candidate for any surgical intervention as his main complaint was back pain. He would
possibly benefit from medial branch blocks and possibly R3 procedure at the L4-5 level
followed by another course of physical therapy if his back pain was improved.
Authorization would be submitted through Dr. Rhee. The applicant would follow-up
with Dr. Rhee to have this procedure and follow-up with Dr. Grant on as needed basis.

(.pdf_Pages 72-73)
Lima, Christopher

Progress Note, signed by Walter Panganiban, M.D., Family Medicine, Stanford

Health Care ValleyCare Occupational Health Services, dated August 23, 2018.

Subjective Complaints: Since last visit, the applicant’s symptoms were overall worse.
He rated his pain level as 7/10. He was currently off work. Therapy had ended. He had
pain in his low back, glutes, down thighs and had lack of mobility. He had a cortisone
injection in July, but stated that made it worse with pain. He had seen his spinal surgeon
who referred him back to the specialist who gave cortisone injection, but he stated that he
did not want to go back to that person. He was in physical therapy, but stopped that since
it made it worse. Work status was off work and stated that he needed form signed and
updated. He was using Norco and Cymbalta for pain. He presented to get a work status.

He was seen by Dr. Rhee and was transferred to Dr. Shinaman for pain management. He
continued to have back pain and was on medications, which was not helping.

Diagnoses: 1) Strain of muscle, fascia and tendon of lower back. 2) Other intervertebral
disc displacement, lumbosacral region.

Treatment Plan: He was advised to see Dr. Shinaman.

(.pdf_Pages 70-71)

Consultation, signed by Richard Shinaman, M.D., Pain Management, Pain Medicine

Consultants, dated October 5, 2018

History of Present Illness: The applicant was an injured fireman with a long history of
back pain. He had pain mainly in the back in a band-like pattern. He did have radiation
to the buttocks. His pain was worse with extension and rotation. He was not typically
weak. He was a fire captain, but was off work currently due to pain and disability. He
was feeling that he would have trouble doing his job. He had seen Dr. Grant and he
advised that there was no singular area that could be addressed. He wanted to try and
avoid opioid medications, but wanted a long-term plan that could help him to function
and enjoy life as much as he could. His records showed that he did take Oxycodone for
severe breakthrough pain. Sleep was a tough issue for him as well. His MRI showed
multiple level foraminal stenosis, but most notably significant facet disease at L4 and L5.

He presented in the office that day having failed more simple conservative technique
such as physical therapy and/or simple analgesics. Either these were not helpful, or he
could not tolerate them, he wanted to pursue more comprehensive multidisciplinary pain
relieving treatments in an effort to decrease overall pain and human suffering.

He presented with persistent complaints related to low back pain. The quality of the pain
was an aching sensation, moderate to severe and chronic in nature. The timing of the
Lima, Christopher

pain was such that it was present too much of the time. The context of the pain was such
that it was present when the he was trying to perform activities of daily living.

Modifying factors of the pain were resting, analgesics, and/or interventional treatments.
Associated signs and symptoms included symptoms such as excessive pain, numbness,
decreased movement, weakness, poor sleep and frustrated mood.

He was on temporary restrictions currently in relation to this industrial injury.

Past Medical History: He has a history of allergies, anxiety, depression and sleep apnea.

Past Surgical History: He underwent dental surgery and tonsillectomy.

Current Medications: He was taking Duloxetine 20 mg and Meloxicam 15 mg.

Allergies: He is allergic to Penicillin V Potassium, Sulfamethoxazole-Trimethoprim,

Tetracycline and Sulfa drugs.

Physical Examination: Gait and station was basically normal besides changes due to
pain. Examination of the joints, bones, and muscles of the affected area revealed
tenderness to deep palpation and stiffness with pain upon range of motion movements.
Areas of painful spasm in the region of the lumbar paraspinals and gluteal muscles was
noted. Range of motion was decreased with lumbar extension. He had pain that was
worse with rotation and extension. He had painful sites to deep palpation in the region of
pain.

Diagnoses: 1) Lumbar spondylolysis. 2) Chronic pain due to trauma. 3) Encounter

related to workers compensation claim. 4) Pain disorder associated with psychological
and physical factors. 5) Chronic prescription opiate use.

Discussion: A trial of bilateral L4-5 and L5-S1 facet injections was advised. Lumbar
TPIs with modalities would be helpful after the facets were addressed. A Nevro device
could be helpful versus a 2 level fusion if nothing else works. Pain treatment related
medications were reviewed and discussed. Muscle stretching, modalities, and/or muscle
activation encouraged. Mindfulness training and/or guided imagery was advised.

(.pdf_Pages 19, 56-62)

Progress Note, signed by Richard Shinaman, M.D., Pain Management, Pain

Medicine Consultants, dated November 2, 2018.
Lima, Christopher

History of Present Illness: The applicant presented with ongoing complaints related to
low back pain. The quality of his pain was aching sensation, moderate to severe and was
chronic in nature. The timing of the pain was such that it was present too much of the
time. The context of the pain was such that it was present when the he was trying to
perform activities of daily living. Modifying factors of the pain were resting, analgesics,
and/or interventional treatments. Associated signs and symptoms included symptoms
such as excessive pain, decreased movement, poor sleep and frustrated mood.

He was very frustrated with ongoing pain and an inability to get better. He wanted to
know what could be fixed. Dr. Grant advised him to have no surgery as that might make
him worse. He wanted to discuss his facet injections. He presented that day related to
the fact that he was having persistent pain and related suffering. He wanted to pursue
ongoing multidisciplinary pain relieving treatments in an effort to decrease the overall
pain and human suffering they experienced due to pain related medical disease. His pain
treatment plan was to try and help to make him suffer less and be more able to perform
the relevant activities of daily living.

Current Medications: He was taking Duloxetine 20 mg, Meloxicam 15 mg and

Tizanidine 4 mg

Diagnoses: 1) Lumbar spondylolysis. 2) Chronic pain due to trauma. 3) Encounter

related to worker’s compensation claim.

Plan: Facet joint injections were discussed in detail. Acupuncture after facet joint
injections was recommended. Mindfulness therapy should be very helpful for him and
was discussed this in detail. Pain treatment related medications were reviewed and
discussed. He was advised to keep utilizing non-medication alternatives for pain relief.
Muscle stretching, modalilities and/or muscle activation was encouraged.

(.pdf_Pages 10-17)

Office Visit, signed by Mahima Jain, P.A., Pain Medicine Consultants, dated
January 10, 2019

History of Present Illness: The applicant complained of hand pain, arm pain and low
back pain.
The quality of the pain was an aching sensation, moderate to severe and chronic in
nature. The timing of the pain was such that it was present too much of the time. The
context of the pain was such that it was present when he was trying to perform activities
of daily living. Modifying factors of the pain were resting, analgesics, and/or
Lima, Christopher

interventional treatments. Associated signs and symptoms include symptoms such as

excessive pain, decreased movement, poor sleep and frustrated mood.

He was post bilateral L4-S1 facet x1 on November 28, which had given him 80% relief
for one month. He was there that day since his pain has returned and reported 8/10 pain.
He had questions about his treatment plan and next steps. He stated that sitting for long
periods were difficult and had non-radicular pain. Medications and exercises had given
minimal relief.

Facet joint injections were required.

He was having persistent pain and related suffering. He wanted to pursue ongoing
multidisciplinary pain relieving treatments in an effort to decrease the overall pain and
human suffering they experienced due to pain-related medical disease.

His pain treatment plan was to try and help to make the him suffer less and perform the
relevant activities of daily living.

Past Medical History: He has a history of allergic, anxiety, depression and sleep apnea.

Past Surgical History: He underwent dental surgery and tonsillectomy.

Medications: He was taking Duloxetine 20 mg, Meloxicam 15 mg and Tizanidine 4 mg.

Allergies: He is allergic Penicillin V Potassium, Sulfamethoxazole-Trimethoprim,

Tetracycline and Sulfa (Sulfonamide Antibiotics).

Physical Examination: Gait and station was basically normal besides changes due to
pain. Examination of the joints, bones, and muscles of the affected area revealed
tenderness to deep palpation and stiffness with pain upon range of motion movements.
Areas of painful spasm in the region of the lumbar paraspinals and gluteal muscles.
Range of motion was notable for decreased ROM with lumbar extension. Assessment of
stability revealed no notable dislocations or subluxation. Muscle strength and tone
assessments revealed gross normal strength. There were no notable red flags present
during the examination. He had pain that was worse with rotation and extension (positive
facet signs). He had painful sites to deep palpation in the region of pain.

Diagnoses: 1) Chronic pain due to trauma. 2) Lumbar spondylolysis. 3) Spondylosis of

lumbar region without myelopathy or radiculopathy.

Plan: He was advised to continue Mobic 15 mg, Tizanidine 4mg, Cymbalta 30 mg.
Recommended repeat bilateral L4-5, L5-S1 facet joint injection and authorization would
be obtained. Recommended acupuncture after facet joint injection. Mindfulness therapy
Lima, Christopher

should be very helpful for him and discussed this in detail. Pain treatment related
medications were reviewed and discussed. He was advised to keep utilizing non-
medication alternatives for pain relief. Muscle stretching, modalities, and/or muscle
activation encouraged.

(.pdf_Pages 1-9)

That completes the review of records.