Doctor: Good afternoon, sir. Welcome in. Let's get started, how old are you?
Patient: Good afternoon, doctor. I'm fifty two years old. 
Doctor: My nurse says that you're here for an independent evaluation, is that correct? 
Patient: Yes sir, that is. 
Doctor: Good, what do you do for a living? 
Patient: Right now, I'm a temporary employee for A B C A B C, I've worked for A B C D, too. 
Doctor: What do you do there?
Patient: Mainly, I handle the loading and unloading of furniture and appliances for people's houses. 
Doctor: That's hard work. When did you get hurt? 
Patient: It was about two and a half weeks ago now, back in October. 
Doctor: Do you have a history of back problems, like before this injury?
Patient: Yeah, I've had back pain for a long time. 
Doctor: What happened when you got hurt this time? 
Patient: I was unloading one of the A B C eighteen wheelers, when I bent down to pick up some boxes, and I felt the pain. 
Doctor: What kind of pain did you feel? 
Patient: I felt a sharp pain in my lower back right away when I tried to lift those boxes. 
Doctor: Does your pain go down your legs?
Patient: Yes, it goes into the right side of my butt, and then all the way down the outside of my right leg, like into the knee. 
Doctor: How have your symptoms progressed since they began?
Patient: Doctor, they've only gotten worse. 
Doctor: Do you have any pain in your left leg?
Patient: A little, not as bad as the right. 
Doctor: What other symptoms are you having besides the pain down your leg? 
Patient: The muscles in my butt are spazzing, and it's happening more and more. 
Doctor: Have you seen another doctor for this? 
Patient: Yes, I saw Doctor Z at first. 
Doctor: What did they do for you?
Patient: He gave me some muscle relaxers, and some, um, Lidocaine patches. 
Doctor: Did this help at all?
Patient: No, not at all. 
Doctor: Who else have you seen?
Patient: I saw doctor X Y Z too, through worker's comp. 
Doctor: When did you see them? 
Patient: That was back in April. 
Doctor: What did they recommend? 
Patient: Um, he sent me for an M R I, and I have the report for that right here. 
Doctor: Okay, this M R I report is basically negative, which is good. Did he give you any medications?
Patient: Yes, he gave me some opioids. 
Doctor: Wow, that's strong stuff. What is your work status right now? 
Patient: Doctor X Y Z put me on restricted duty status, doctor. 
Doctor: I'm reading your notes from doctor X Y Z, he says he released you in June, and that you have reached maximum medical improvement. 
Patient: He told me that, but I still have pain, so I went back to see him. 
Doctor: When you went for follow up, did you still have that pain down your legs? 
Patient: Yes, I did. 
Doctor: What did doctor X Y Z recommend at that time? 
Patient: He referred me to a Pain Clinic, and he recommended I have, um, epidural injections with doctor A B C. 
Doctor: Did you have this done? 
Patient: Yes, I did. 
Doctor: Did this help at all? 
Patient: No, it did absolutely nothing. 
Doctor: Okay, so after that, what treatment did you have? 
Patient: I had an M R I, um, E M G, and nerve conduction study with doctor A B C D. 
Doctor: Do you have the results of that as well? 
Patient: Yes, doctor, they're right here. 
Doctor: Okay, sir, these tests are essentially normal, which is more good news. What aggravates your pain?
Patient: Well, anything like sitting for a long time. When I do that, I feel it in my legs. 
Doctor: When you sit for a long time, is it in both legs?
Patient: It's really on my right. 
Doctor: Are you able to sleep at night?
Patient: No, sir, I'm not able to sleep at all. 
Doctor: Have you been able to return to work?
Patient: Well, I went back to work in June, after doctor X said I'd reached the maximum medical improvement we talked about.
Doctor: Finally, have you seen a chiropractor for this pain? 
Patient: Yeah, I saw doctor X about eight or nine times. 
Doctor: Did they do anything to help you feel better?
Patient: Really, no, it did not. I still have the pain down my legs today.

Clinical note:
Symptoms: Sharp lower back pain with radiation down right buttock and leg, muscle spasms in buttocks, worsened pain with sitting and stooping, difficulty sleeping due to pain
Diagnosis: Lumbar radiculopathy
History of Patient: Work-related injury involving lifting heavy objects, history of chronic back pain, unsuccessful treatment with muscle relaxers, lidocaine patches, opioids, epidural steroid injections, and chiropractic care
Plan of Action: Further evaluation and treatment options for lumbar radiculopathy, considering alternative therapies for pain management