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 - 1

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

ALLOWED CONDITIONS: Left knee strain, meniscus tear left knee.
CONTESTED CONDITION: Osteoarthritis of the left knee.

I examined Xxxxx today September 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee. He is a 57-year-old assembly worker who was injured on June 13, 2007, which according to his FROI was due to "repairing cars, down on knees to work on concrete floors." In addition, he slipped on an air hose on the floor at work on March 7, 2007, re-injuring his left knee. He developed pain and swelling in his left knee. He denies having any difficulties with his left knee prior to the injury of June 13, 2002.

DIAGNOSTIC STUDIES: August 2, 2002, MRI of the left knee showed low-grade chondromalacia of the left patellofemoral joint space and a posterior horn tear of the medial meniscus, likely degenerative in nature, and also grade II to III chondromalacia of the medial joint space. On June 26, 2007, MRI of his left knee was referred to in the injury management report of June 19, 2007, as showing osteoarthritis of the medial compartment has advanced. He brought with him copies of x-rays taken July 16, 2007, of his left knee, which I reviewed and which showed marked narrowing of the medial compartment of his left knee with spurs on the margins of the joint medially and also spurs on the patella. There was subluxation of the tibia on the femur with standing.

After his injury, he received treatment from Dr. X for patellofemoral syndrome with knee sleeve. He also received treatment from Dr. Y also for left knee sprain and patellar pain. He also did exercise, does use a knee sleeve and Aleve. On December 5, 2002, he underwent arthroscopy of the left knee by Dr. Z who did a partial resection of a torn medial meniscus. He also noticed grade III chondromalacia of the patella as well as the torn medial meniscus. He states that he was asymptomatic until he slipped on an air hose while at work on March 7, 2007, and again developed pain and swelling in his left knee. Standing aggravates his pain. He has had one injection of cortisone by Dr. Z about a month ago, which has helped his pain. He takes one hydrocodone 7.5/750 mg daily.

Examination of his left knee revealed there was bilateral varus deformity, healed arthroscopy incisional scars, there was a 1/2 atrophy of the left calf. There was patellar crepitus with knee motion. There was no motor weakness or reflex changes. He walked without a limp and could stand on his heels and toes equally well. There was no instability of the knee and no effusion. Range of motion was 0 to 120 degrees.

QUESTION: Xxxxx has recently filed to reactivate this claim. Please give me your opinion as to whether Xxxxx's current clinical presentation is related to the industrial injury stated above.

ANSWER: Yes. His original MRI of August 2, 2002, did show low-grade chondromalacia of the patellofemoral joint and also grade II to III chondromalacia of the medial joint space, which was the beginning of osteoarthritis. Also, it is well known that torn medial meniscus can result in osteoarthritis of the knee; therefore, the osteoarthritis is related to his original injury of June 13, 2007, specifically to the torn medial meniscus.

QUESTION: Do I believe that claim #123 should be reactivated to allow for treatment of the allowed conditions as stated?

ANSWER: Yes, I believe it should be reactivated to allow treatment of the contested condition of osteoarthritis of his left knee.

QUESTION: Xxxxx has filed an application for additional allowance of osteoarthritis of the left knee. Based on the current objective findings, mechanism of injury, medical records, and diagnostic studies, does the medical evidence support the existence of the requested condition?

ANSWER: Yes. Please see the discussion in the answer to question no one. In addition, x-rays of July 16, 2007, do reveal medial compartment and patellofemoral compartment osteoarthritis of the left knee.

QUESTION: If you find this condition exists, is it a direct and proximate result of the June 13, 2002, injury?

ANSWER: Yes. See discussion in answer to question number one.

QUESTION: Do you find that Xxxxx's injury or disability was caused by the natural deterioration of tissue, an organ or part of body?

ANSWER: No. I believe the osteoarthritis was the result of the torn medial meniscus as discussed under question number one.

QUESTION: In addition, if you find the condition exists, are there non-occupational activities or intervening injuries, which could have contributed to Xxxxx's condition?

ANSWER: No. He does not give any history of any intervening injuries.

If you opine the requested condition should be additionally recognized, please include the condition as an allowed condition in the discussion of the following questions.

QUESTION: Based on the objective findings is the request for 10 sessions of physical therapy per C-9 dated July 27, 2007, medically necessary and appropriate for the allowed conditions of the claim of osteoarthritis of left knee?


Keywords: ime-qme-work comp etc., osteoarthritis, occupational medicine, medial meniscus, injured, knee,
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