October 15, 2012 - City of Laredo

liftlcany objects more than 10 lbs, and may only work a maximum of 8 hours a day starting on 1/6/20 1 1
until next follow-up on 1/10/2011. At which point the employee worked 2 days of modified duty.
01/10/2011- Lt. Ramon was seen by Dr. F.J. Gutierrez again for follow-up, continued with head contusion,
back pain, and neck sprain, and was taken off of work until next appointment on 1/17/2011 pending further
evaluation.
01/14/2011- Lt. Ramon had:
MRI of Lumbar Spine WIO contrast showing
1) Herniated Disc at L4-L5 as described with compromise of the Neuroforamina bilaterally.
2) Minimal Facet Joint Disease at the L4-L5 level.
MRI of the Pelvis WIO contrast showing
1) Normal MRI of the Pelvis
MRI of the Brain W/O contrast showing
1) Normal MRI of the Brain
01/17/2011- Lt. Ramon was seen by Dr. F.J. Gutierrez where the employee was diagnosed having a
Lumbar Disc Hernia, and was referred to a spine specialist. The employee was kept off work until the next
follow-up on 113 11201 1 pending further evaluation.
01/31/2011- Lt. Ramon was seen by Dr. F.J. Gutierrez continues with the lumbar disc hernia, and was
referred to a spine specialist. The employee was kept off work until the next follow-up on 21151201 1
pending further evaluation.
02/15/2011 - Lt. Ramon was seen by Dr. F.J. Gutierrez where the employee was diagnosed having low
back pain and radiculopathy and the employee remained off work until next follow-up on 3/8/2011 pending
further evaluation.
02/17/2011- Lt. Ramon had a diagnostic exam of Lumbar APILaterallFlexionlExtension (Lumbosacral
Spine four views) showing Mild degenerative disc disease at L4-L5-S-1 with mild spondylosis, and no
evidence of instability.
02/17/2011- Lt. Ramon was seen by Dr. A.R. Garza-Vale, Spine Specialist, and kept Lt. Ramon off of
work and recommends conservative treatment in accordance with ODG including physical therapy and
injection to be done in Laredo. After all conservative treatments have been exhausted he is to proceed with
surgery.
03/08/2011- Lt. Ramon was seen by Dr. F.J. Gutierrez and continued with low back pain and radiculopathy
and remains off work until next follow-up on 4/51201 1 pending further evaluation.
03/11/2011-04/01/2011- Lt. Ramon was seen by Orthopaedic Rehab & Sports Medicine Center for physical
therapy.
04/05/2011 - Lt. Ramon was seen by Dr. F.J. Gutierrez continued with low back pain and radiculopathy
and remained off work until next follow-up on 5151201 1 pending further evaluation.
05/05/2011 - Lt. Ramon was seen by Dr. F.J. Gutierrez and continued with low back pain and
radiculopathy to L4 and L5 and remained off work until next follow-up on 6/2/2011 pending further
evaluation.
06/02/2011- Lt. Ramon was seen by Dr. F.J. Gutierrez and continued with low back pain and remained off
work until next follow-up on 61231201 1 pending further evaluation.
06/21/2011- Lt. Ramon was seen by Dr. A Garza-Vale where he retracts previous statements of disc
herniation because one is not seen on the last test, but did see an annular tear, in which, he recommended
another MRI be done to ensure his diagnosis was accurate and that the employee continue on conservative
treatment until next MRI shows different results.
06/23/2011- Lt. Ramon was seen by Dr. F.J. Gutierrez and continued with low back pain and radiculopathy
to L4 and L5 and remains off work until next follow-up on 71131201 1 pending further evaluation.
07/13/2011 - Lt. Ramon was seen by Dr. F.J. Gutierrez and continued with low back pain and remained off
work until next follow-up on 811 51201 1 pending further evaluation.