93 East Ave.   3A
Norwalk, CT 06851
838-3769

April 17, 2002

She is a 42 year old woman who has had back pain for several months since January. She started working at Dunkin’ Donuts and was on her feet for 8 hours a day. She doesn’t really think that this is a work-related injury, and there was no specific trauma at work. She also does housework at home and perhaps aggravated her back somehow. She has never had any previous problems.

She has been under the care of a chiropractor, Dr Sloves, and the treatments are helping. She recently had an MRI of the lumbar spine which showed a disc bulge with degeneration at L5 – S1. There was some impingement on the thecal sac and on the right nerve root.

She has been taking Advil and has been out of work for about a month. She doesn’t really feel that she is improving.

She walked with a slight limp, but this seemed to be more due to pain. There was limited motion of her spine with only about 60° of flexion. Leg-raising was slightly uncomfortable at 90° over the right side. Neurological testing was intact, and reflexes were active and symmetrical.

I would like her to continue restricted activity. I am keeping her out of work until May 9. I will see her again in three weeks.

cc: Dr. Sloves