Sample Name: Chiropractic IME - 1
Description: Chiropractic IME with answers to questions from Insurance Company.
(Medical Transcription Sample Report)
P.O. Box 12345
RE: EXAMINEE : Abc
CLAIM NUMBER : 12345-67890
DATE OF INJURY : April 20, 2003
DATE OF EXAMINATION : August 26, 2003
EXAMINING PHYSICIANS : Y Z, DC
CHIEF COMPLAINTS: Improved focal lower back pain.
HISTORY: Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks "un poquito" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a "stacker." He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had "a little" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under "previous occurrence of the same pain" a notation of "Yes, but it was not really the same, it was just a little and tolerable." There is an additional note on the side which states "no pain prior to this injury or on that day, occasional (but low back)." Saw this notation, he says today that he did not state this and that the form was done by "Edna" at Dr. Abcd's office.
Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.
Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.
PAST HISTORY: Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.
SOCIO-ECONOMIC HISTORY: Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.
Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.
Military History: He has no military experience in his life.
PHYSICAL EXAMINATION: Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.
Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.
Active lumbar ranges of motion with double inclinometer are:
Flexion 70 degrees.
Extension 20 degrees.
Side bending symmetric at 28 degrees.
He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.
Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.
Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.
Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.
In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.
On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.
Mr. Abc tolerated the examination process without apparent or expressed ill effect.
IMAGING STUDIES: AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.
DIAGNOSIS: Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.
SUMMARY: Discussion and recommendations in response to questions posed in your August 15, 2003 letter:
1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.
The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.
2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.
It would appear that the work injury was the major contributing cause of the diagnosis.
3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).
Mr. Abc denies and does not report any off work activities or other contribution that would be a factor. He does have evidence of a transitional lumbosacral region which may somewhat predispose him to lower back pain. There appears to be some inconsistencies in the records regarding the above noted history concerning a patient information form that notes prior lower back symptoms, which he denies today. This could be related to the transitional lumbosacral area.
4. Is Mr. Abc receiving any objective improvement from continued chiropractic treatment? Would there be any benefit to him receiving further chiropractic treatment?
It would seem at this time that Mr. Abc is not receiving any objective improvement from continued chiropractic treatment. He reported on questioning that following the chiropractic treatment, he sometimes actually feels worse for an hour and sometimes no change, but does not note any significant overall improvement even on a temporary basis. He also does not feel that he has had any significant overall change in the last couple of months. The chart notes do not document any significant objective improvement, and therefore I feel that his continued care in all probability is not providing him with any overall material benefit at this time.
5. When, in your opinion, will this condition reach a medical stationary status? Please advise what treatment will be undertaken to promote the worker's recovery by this date.
I feel that he has reached a point of maximum improvement and is medically stationary.
6. If the worker's condition is considered medically stationary, please indicate the objective findings that include:
He is medically stationary at this time and has essentially normal objective findings.
A. Please provide active range of motion in degrees measured by inclinometer (flexion, extension, lateral flexion, rotations). Please use the attached form to report this information.
His ranges of motion measured by double inclinometer are as above.
B. Are the range of motion findings you report, as demonstrated by the worker, considered normal for this individual?
They are considered normal for this individual.
C. If the range of motion is not considered normal for this individual, are these findings a direct consequence of the injury?
D. Are the range of motion findings valid for the purpose of rating permanent impairment (i.e. straight leg raise validity criteria met, reproducibility within +/- 10% or 5 degrees)? Please provide your rationale based on sound medical principles, explaining why they are or are not valid.
His ranges of motion findings are considered valid; however again, we do not feel that he has any permanent impairment as a result of the industrial injury.
E. Please indicate whether there are areas of sensory changes. If yes, provide two-point discrimination for the palmar surface of the fingers and/or hands, and the plantar surface of the feet, and a statement of partial or total loss for the plantar surface of the foot.
There is no evidence of any sensory loss or change.
F. Please provide strength on a 0/5 scale and identify the specific nerve or muscle causing the weakness. Please do NOT provide on the "motion" (i.e. flexion and extension).
His muscle strength testing is 5/5 and normal.
G. Is the worker capable of regular work?
He is doing his normal work at this time, and there are no findings that would preclude him from continuing in his full work duties as a stacker.
H. If the worker cannot perform regular work, please provide occasional lift in pounds.
I. If applicable, please indicate restrictions in: sitting, standing, or walking less than two (2) hours at a time; working the same amount of hours as worked at the time of injury; stooping, bending, crouching, crawling, kneeling, twisting, climbing, balancing, reaching, pushing, or pulling.
7. Please identify any permanent chronic medical condition that exists and that precludes the worker from repetitively using the low back. If there is no indication of such a condition, please state this opinion.
There are no permanent chronic medical conditions that exist that would preclude him from repetitive use of his back. He does have suggested transitional lumbosacral area; however, I do not feel that this is a significant contributor, nor does it preclude him from functioning in his normal capacity as a stacker or similar occupation.
8. Please indicate, based on your examination, what percentage of the impairment, if any, is due to the industrial injury and what percentage is due to any preexisting condition? (Please note: definition of preexisting condition listed above.)
There is no evidence of impairment.
9. If findings of permanent impairment exist, do you expect there will be periods of waxing and waning of symptoms that may result in additional medical services and/or periods of temporary disability? Please provide your best assessment as to what can be reasonably anticipated.
I do not anticipate periods of waxing and waning of symptoms resulting from the industrial injury, believing that he has essentially recovered at this time. His residual symptoms should gradually abate with the "tincture of time," with no additional treatment or investigation required. I feel that any ongoing complaints beyond the next month or so would be in all probability secondary to more contemporary activities and concerns, with possibly some contribution from the transitional lumbosacral area; however, I do not feel that this is a significant factor.
I trust that this report adequately addresses your concerns. Thank you for requesting my opinion.
Dictated by: Y Z, DC
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