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: Records Review - Epicondylitis

Description: Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.
(Medical Transcription Sample Report)

ALLOWED CONDITIONS: Lateral epicondylitis, right elbow

EMPLOYER: ABCD

REQUESTED ALLOWANCE: Carpal tunnel syndrome right.

Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars. He does state he was employed for such company for the last five years. His work includes lots of pulling, pushing, and working in weird angles. He does state on the date of injury, he was not doing anything additional.

TREATMENT HISTORY: Thereafter, he developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger. He was initially seen by Dr. X on October 18, 2007, at the Occupational Health Facility. He utilized a tennis elbow brace, but did continue to experience symptomatology into the middle, ring, and small finger. He was placed on light duty for the next couple of months. Mr. XXXX suffered another work injury to the right shoulder on October 11, 2007. He did undergo arthroscopic rotator cuff repair by Dr. Y in December of 2007. Thereafter, he continued to work in a light duty type of basis for the next few months.

An EMG and nerve conduction study was performed in December of 2008, which demonstrated evidence of carpal tunnel syndrome. He was able to return to work doing more of a light duty type of position.

The injured worker has also seen Dr. Y once again subsequent to the EMG and nerve conduction study on December 3, 2008. It was felt that the injured worker would benefit from decompression of the carpal tunnel and an ulnar nerve transposition. The injured worker subsequently was placed in a no work status thereafter.

At the present time, the injured worker does complain of light tingling into the small, ring, and middle finger. There are times when the whole hand becomes very numb. He does not use and do any type of lifting with regards to the right hand secondary to the discomfort. His pain does vary between a 4 on a scale of 1 to 10. He denies any weakness. He does not awaken at night with the symptomatology. Doing his job is the only causation as related to the carpal tunnel syndrome and the cubital tunnel type symptoms. He does state that he is right-handed.

In addition, he does note numbness and tingling as related to the left hand. He has not had any type of EMG and nerve conduction study as related to the left upper extremity.

CURRENT MEDICATIONS: None.

ALLERGIES: Zyrtec.

SURGERIES: Left shoulder surgery.

SOCIAL HISTORY: The injured worker denies tobacco or alcohol consumption.

PHYSICAL EXAMINATION: Healthy-appearing 41-year-old male, who is 5 feet 8 inches, weighs 205 pounds. He does not appear to be in distress at this time.

On examination of the right upper extremity, one can appreciate no evidence of swelling, discoloration or ecchymosis. The range of motion of the right wrist reveals flexion is 50 degrees, dorsiflexion 60 degrees, ulnar deviation 30 degrees, radial deviation 20 degrees. Tinel's and Phalen's tests were positive. Reverse Phalen's test was negative. There is diminished sensation in distribution of the thumb, index, middle, and ring finger. The intrinsic function did appear to be intact. The injured worker does not demonstrate any evidence of difficulties as related to extension of the middle, ring, and index finger as related to the elbow. The range of motion of the right elbow reveals flexion 140 degrees, extension 0 degrees, pronation and supination 80 degrees. Tinel's test is negative as related to the elbow and the ulnar nerve.

There is noted to be satisfactory strength as related to major motor groups of the right upper extremity.

RECORDS REVIEW:
1. First report of injury, difficulty as related to both hands.
2. Number of notes of Occupational Health Clinic. It was felt that the injured worker did indeed suffer from median nerve entrapment at the wrist and ulnar nerve entrapment at the right elbow with the associated right lateral epicondylitis.
3. December 20, 2007, operative note of Dr. Y. At which time, the injured worker underwent arthroscopic rotator cuff repair, subacromial decompression, partial synovectomy of the anterior compartment, limited debridement of the partial superior-sided subscapularis tear without evidence of subacromial impingement.
4. November 17, 2008, EMG and nerve conduction study, which demonstrated moderate right median neuropathy plus carpal tunnel syndrome.

ASSESSMENT: Please state your opinion for the following questions based upon your review of the enclosed medical records on January 23, 2009, examination of the claimant.

Please indicate whether the restriction given on December 3, 2008, is the result of the allowed condition of lateral epicondylitis.

It should be noted on physical examination that the symptomatology as related to the lateral epicondylitis have very much resolved as of January 23, 2009. Resisted extension of the middle finger and wrist do not cause any pain about the lateral epicondylar region. It also should be noted that really there is no significant weakness as related to the function of the right upper extremity. Also noted is there is an absence of tenderness as related to the lateral epicondylar region.

QUESTION: Has the claimant reached maximum medical improvement for the allowed conditions of lateral epicondylitis? Please explain.

ANSWER: Based upon the examination on January 23, 2009, the injured worker has indeed reached maximum medical improvement as related to the diagnosis of lateral epicondylitis. This is based upon review of the medical records, evidence-based medicine, and the Official Disability Guidelines.

QUESTION: Please indicate whether the allowed condition of lateral epicondylitis has temporarily and totally disabled the claimant from December 8, 2008 through February 1, 2009, and continuing. Please explain.

ANSWER: There is insufficient medical evidence and it is my opinion to state that the allowed condition of lateral epicondylitis is not temporarily and totally disabling the claimant from December 8, 2008 through February 1, 2009, and continuing. As mentioned the symptomatology referable to the lateral epicondylar region has very much resolved based upon the examination performed on January 23, 2009.

QUESTION: If it is your opinion that the claimant is temporarily and totally disabled due to allowed condition of lateral epicondylitis, please indicate what treatment the claimant must undergo in order to achieve a plateau of maximum medical improvement. Please also give an estimated time for maximum medical improvement.

ANSWER: The injured worker has indeed reached maximum medical improvement as related to the elbow. There is no question that the injured worker is not temporarily and totally disabled due to the allowed condition of lateral epicondylitis. At the time of the exam, the injured worker has indeed reached maximum medical improvement as related to lateral epicondylitis as described previously.

QUESTION: Is the claimant suffering from carpal tunnel syndrome, right?

ANSWER: The claimant does suffer from the condition of carpal tunnel syndrome, right. This is very much based upon the EMG and nerve conduction study obtained on October 17, 2008.

QUESTION: If the claimant does suffer from the condition of carpal tunnel syndrome, right, is it the result of his September 11, 2007, work injury?

ANSWER: It is my opinion, it does appear based upon the symptomatology of September 11, 2007, approximately one day subsequent to the date of injury that the injured worker did indeed have evidence of symptomatology referable to the index, middle, and ring finger very much compatible to carpal tunnel syndrome. Thus the condition of carpal tunnel syndrome, right, is not the direct and proximate result of the September 11, 2007, work injury.

QUESTION: If it is your opinion that the claimant suffers from carpal tunnel syndrome, right, as a result of his work injury, please indicate whether you believe the claimant is capable to returning to his former position of employment with or without restrictions. If the claimant has restrictions, please detail what they are?

ANSWER: It is my opinion that the claimant does indeed suffer from right carpal tunnel syndrome. There is no question this is very much based upon the overactivity as related to utilization of the right wrist and hand. The claimant is capable to return to his former position of employment. He indeed very much needs to avoid those activities that cause pain as related to utilization of the right upper extremity.

QUESTION: If it is your opinion that the claimant is temporarily and totally disabled due to carpal tunnel syndrome, right, please indicate what treatment the claimant must undergo in order to achieve a plateau of maximum medical improvement. Please be sure to indicate the estimated length of time for the claimant to achieve a plateau of maximum medical improvement.

ANSWER: Based upon review of the independent medical examination and review of the symptomatology that the injured worker would benefit from surgical intervention as related to the right elbow. Determination needs to be made whether or not to proceed with the decompression of both the ulnar and median nerve based upon this exam. This determination needs to be rendered about the need for surgical intervention as related to the right wrist and hand.

This information is based upon review of the medical records and independent medical examination performed. If you have any further questions as related to the evaluation, please feel free to contact my office.

Keywords: ime-qme-work comp etc., records review, carpal tunnel syndrome, nerve conduction study, maximum medical improvement, lateral epicondylitis, carpal tunnel, injured worker, medical improvement, nerve, epicondylitis, elbow, syndrome, claimant, hand,
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