Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Occupational Medicine Consult

Description: Occupational medicine consult with questions-answers and records review.
(Medical Transcription Sample Report)

ALLOWED CONDITION: Right shoulder sprain and right rotator cuff tear (partial).
CONTESTED CONDITION: AC joint arthrosis right aggravation.
DISALLOWED CONDITION: Right shoulder impingement syndrome.
EMPLOYER: ABCD

I examined XXXXXXX today September 14, 2007, for the above allowed conditions and also the contested condition of AC joint arthrosis of the right (aggravation). She states that she was injured on December 4, 2001, "I was using my right arm to paint with under the bonnet and trunk inside the __________ putting props with her right arm for the trunk and the bonnet, and taking the props out of the trunk and bonnet and painting with the right arm. She denies having symptoms or any injury with right shoulder prior to December 4, 2000. It is noted that there is a lapse and care from August 2002 until October 2006. She received treatment from Dr. X that consisted of massage therapy, Darvocet, and Ultracet. She also saw Dr. Y who recommended a Mumford procedure, decompression and rotator cuff tear. He felt that she did not have an impingement syndrome.

DIAGNOSTIC STUDIES: August 6, 2002, MRI right shoulder showed a partial rotator cuff tear of the supraspinatus. June 25, 2007, MRI of the right shoulder showed minimal degenerative change of the acromioclavicular joint. A partial bursal side tear of the supraspinatus with tendinopathy of the supraspinatus and infraspinatus and subscapularis.

According to the patient surgery was performed on August 6, 2007, by Dr. Z, which according to the patient was a repair of a torn rotator cuff and a Mumford. There is no operative report available in the records.

RECORDS REVIEWED:
1. March 7, 2001, FROI.
2. April 9, 2007, Dr. Y, IME
3. July 10, 2007, Dr. Z, M.D., office notes in which he stated there was no impingement syndrome.
4. May 17, 2007, Dr. X, office notes who first saw her on May 17, 2007.

PHYSICAL EXAMINATION: Due to her recent surgery on August 6, 2007, only a limited physical examination could be performed. There was a healing 1-1/2 inch saber cut incision over the anterior aspect of the right shoulder, which was tender. She also had tenderness in the clavicle as well as the AC joint and the head of the humerus. Reflexes were intact. There was no sensory loss. No evidence for causalgia, peripheral vascular disease, or an arthroplasty. Range of motion was not performed due to the recent surgery and her motor power; however, shoulder was not tested due to the recent rotator cuff repair.

QUESTION: Ms. XXXXX has filed an application for the additional allowance of aggravation of the right AC joint arthrosis. Based on the current objective findings, mechanism of injury, medical records, or diagnostic studies, does the medical evidence support the existence of the requested condition?

ANSWER: Yes. Her MRI of June 25, 2007, did state that there was minimal degenerative change in the AC joint. Therefore, the condition does exist.

QUESTION: If you find this condition exists is it a direct and proximate result of the December 4, 2000, injury?

ANSWER: No. This is a degenerative condition, nontraumatic, and certainly the mechanism of injury, which I described under history, would not have injured the acromioclavicular joint. There also is no objective evidence that this was aggravated by the injury, as there are no objective records after her injury of December 4, 2000, which would document that.

QUESTION: Do you find that Ms. XXXXX's injury or disability is caused by natural deterioration of tissue, an organ, or part of the body.

ANSWER: Yes. Osteoarthritis of the acromioclavicular joint or degenerative changes of the acromioclavicular joint or as the word states a degenerative condition nontraumatic that is on the basis of a natural deterioration of tissue and not on the basis of the injury and specifically not the injury of December 4, 2000.

QUESTION: In addition, if you find that there condition exists, are there non occupational activities or intervening injuries that could have contributed to Ms. XXXXX's condition?

ANSWER: She denies having any injury to her shoulder other than the repetitive motion of her job and there are no other occupational activities that would have contributed to this.

Keywords: ime-qme-work comp etc., allowed condition, contested condition, disallowed condition, employer, records reviewed, occupational medicine, joint arthrosis, rotator cuff, ac joint,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples