Sample Name: Qualified Medical Evaluation Report
Description: Qualified medical evaluation report of a patient with back pain.
(Medical Transcription Sample Report)
HISTORY OF INJURY AND PRESENT COMPLAINTS: The patient is a 59-year-old gentleman. He is complaining chiefly of persistent lower back pain. He states the pain is of a rather constant nature. He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back. He states he has difficulty with prolonged standing or sitting. He can only stand for about 5-10 minutes, then he has to sit down. He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain. He has difficulty with bending and stooping maneuvers. He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot. He gets numbness along the lateral aspect of the foot itself. He also describes chronic pain complaints with associated tension in the back of his neck. He states the pain is of a constant nature in his neck. He states he gets pain that radiates into the right shoulder girdle area and the right forearm. He describes some numbness along the lateral aspect of the right forearm. He states he has trouble trying to use his arm at or above shoulder height. He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity. He describes pain at the anterior aspect of his shoulder, in particular. He denies any headache complaints. He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person. He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck. He lost his footing and fell. He reached out to grab the hand railing. He fell backwards on his back and his right shoulder. He had immediate onset of shoulder pain, neck pain, and low back pain. He had pain into his right leg. He initially came under the care of Dr. H, an occupational physician in Modesto. Initially, he did not obtain any MRIs or x-rays. He did undergo some physical therapy and received some medications. Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful. The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990. He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat. He continues with rather persistent pain in his right shoulder. He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff. The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories. He felt that the patient might require a cortisone injection or possibly a surgical intervention. The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck. There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels. The patient was also seen by Dr. P, a neurologist for a Neurology consult. It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities. The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994. He returned back to regular duty. Dr. N declared him permanent and stationary on 04/04/1995. The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer. At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician. Dr. N took him off work again. He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon. He had a new MRI of his lumbar spine performed. The MRI was performed on 05/20/1997. It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis. The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam. Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation. Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive. The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left. Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities. The patient did see Dr. R for a neurosurgical consult. Dr. R evaluated both his neck and lower back pain complaints on several occasions. Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks. The patient underwent these injections with Dr. K. The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections. It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine. Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness. The patient also was noted to have a C4-5 with rather severe degenerative disc disease. He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6. Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease. He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1. He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain. He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation.
The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms. He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him. He is currently taking no medications to manage his pain complaints. He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury. He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician. The patient states he has not been back to work since. He has since applied for social security disability and now is receiving social security disability benefits. The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful. Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.
PAST MEDICAL HISTORY: Unremarkable for medical problems. He relates no prior injury issues other than the two industrial injuries described above in my report.
PAST SURGICAL HISTORY: He has had tonsillectomy. He relates no other surgeries.
CURRENT MEDICATIONS: Currently none.
SOCIAL HISTORY: He denies tobacco or alcohol use. He is currently on social security disability. He has been off work for over a year. He is married. He has four children. He does relate that he had a history of alcoholism. He quit drinking at age 23. He has not taken a drink for the past 37 years.
REVIEW OF SYSTEMS:
General: No recent weight gain or weight loss. No fevers or chills.
HEENT: No headaches, earaches, or nose or throat symptoms.
Cardiopulmonary: No chest pain, shortness of breath, or palpitations.
Gastrointestinal: No abdominal pains, nausea, or vomiting.
Genitourinary: No dysuria, polyuria, or hematuria.
PHYSICAL EXAMINATION: He stands five feet nine inches in height. He weighs 197 pounds. His blood pressure is 112/78, pulse 92, respirations 20. His HEENT is PERRLA, EOMI. Thyroid is midline and not enlarged. Throat is not injected. Lungs are clear. Heart is regular rate and rhythm without murmurs. Abdomen is soft and nontender, nondistended, positive bowel sounds heard throughout. Lower extremities are without pedal edema. There are +1 distal pulses equally. Examination of the cervical spine revealed some mild decreased range of motion. Both right and left rotation are about 70 degrees, flexion is to 40 degrees, extension to 40 degrees. Right and left lateral bending are about 40 degrees. Cervical compression test causes pain reproduction in his neck and to radiate into the right shoulder girdle area. Palpation reveals some mild hypertonicity in the right cervical trapezius muscles in the right side of his neck. Hoffman sign is negative. DTRs are absent at the right biceps, but +1 at the right brachioradialis and right triceps. They are +1 at the left biceps, triceps and brachioradialis. Sensation is altered to light touch and pin prick along the lateral aspect of the right forearm in comparison to its counterpart on the left. On motor strength, he exhibits 4/5 weakness in right shoulder abduction and right forearm flexion. He is 5/5 in right forearm extension. He has 5/5 strength in all the muscle groups tested in the left upper extremity. Phalen's and Tinel's signs are negative at the wrist and hands. Tinel's sign is negative at the wrist and the ulnar nerve transposition sites of both the elbows. There is no translation of the ulnar nerve on flexion and extension of the elbows themselves. Examination of the lumbar spine reveals diminished trunk range of motion with flexion allowing his fingertips to grasp just below his knees only, extension to about 30 degrees. Right and left SLRs are both to about 80 degrees causing right-sided back pain, more so than the left side. Braggard's maneuver is negative. Valsalva maneuver causes low back pain, but does not radiate. DTRs are +1 at the knees, +1 at the ankles. His toes are downgoing to plantar reflex bilaterally. Sensation is somewhat altered, decreased at the lateral aspect of the right foot and calf in comparison to its counterpart on the left. His motor strength appears 5/5 strength in the lower extremity muscle groups tested. Examination of the right shoulder reveals decreased range of motion. Lateral abduction is to about 120 degrees, full forward flexion to 120 degrees, extension to 30 degrees, external rotation to 60 degrees. On internal rotation, he can place his thumb in the lower lumbar region only. Palpation reveals tenderness in the right subacromial region of the shoulder. There is a positive impingement sign on the right shoulder. There is some disuse atrophy in the right anterior shoulder girdle itself by comparison visually of the left shoulder. Circumferential measurements were taken in this right-hand-dominant individual. The right biceps is 12 inches, left biceps is 13 inches, both right and left forearm are 11 inches. There is at least one inch of disuse atrophy in the right biceps itself. There is no retraction of the biceps belly. There is no sign rupture of the biceps belly. Circumferential measurements of the lower extremities were 20 inches at both right and left thighs, 15 inches at both right and left calves. Jamar dynamometry was taken on three tries. He has 60/60/60 pounds in the right dominant arm; on the left, it was 80/82/80 pounds suggesting at least 25-30% loss of pre-injury grip strength in the right dominant upper extremity.
IMPRESSION: (1) Cervical spondylosis with history of disc herniation on the right at C5-6 with right-sided C6 distribution numbness. (2) Lumbar degenerative disc disease with disc bulges with history sprain/strain injury to the lumbosacral spine with chronic myofascial pain disorder. (3) History of impingement syndrome with sprain/strain injury to the right shoulder with tendinopathy of the biceps tendon and tenosynovitis of the biceps and supraspinatus tendons. Also, with a history of pinhole tear of the right rotator cuff. (4) Disuse atrophy in the right biceps muscle.
OPINION AND SUMMARY: The patient chronicles an industrial injury to his back, right hip, and right shoulder and neck from an industrial fall from his work truck occurring initially on 06/29/1994. He was seen initially by Dr. H, an occupational physician. He received chiropractic care with Dr. Q. He then transferred his care to Dr. N, a chiropractor, who had seen him previously for lower back pain complaints back in 1990. The patient had MRIs of his cervical and lumbar spine and right shoulder performed following this initial injury event. He had objective findings of a pinhole tear of the right supraspinatus tendon with tendinopathy involving the supraspinatus tendon and biceps tendon of the right shoulder with prominent impingement. His MRIs of the cervical and lumbar spine revealed degenerative disc disease and disc bulges in both the cervical spine and the lumbar spine. There was some suspicion of disc herniation at L4-5 initially in his lower back causing the right leg radiculopathy. He received conservative chiropractic care for six months following the injury. He returned back to his usual and customary work duties. He was declared permanent stationary by Dr. N on 04/04/1995. The patient then incurred another industrial injury on 03/29/1997 while loading some pallets on the back of his trailer, particularly with the onset or flare-up of low back pain and right leg symptoms again. The patient was again seen by Dr. N. The patient also obtained a new MRI of his lumbar spine. The patient also had a Neurology consult with Dr. P. The patient was also seen for a neurosurgical consult with Dr. M. Dr. M did not feel that he was a surgical candidate. Apparently, Dr. M reviewed his previous MRI with a more recent MRI of the lumbar spine which revealed a resolution of a prior herniated disc on the right at L4-5. However, Dr. M was concerned about his recurrence of neck pain and felt that he should have an EMG of the right upper extremity. He felt that he had some radiculopathy and may require an updated MRI of the cervical spine. The patient was also seen by Dr. P, an orthopedic surgeon to evaluate his shoulder pain complaints. Dr. P offered conservative treatment in the way of physical therapy and antiinflammatories initially. Dr. P felt that if his shoulder did not improve, he might be a candidate for a cortisone injection or possible surgical intervention about his right shoulder. The patient has elected not to undergo any surgical procedures this far or interventional procedures about his shoulder. However, the patient was also seen by Dr. R, a neurosurgeon who felt that he had a C6 paresthesia in the right upper extremity related to a C5-6 right-sided disc herniation in his neck. He also noted degenerative disc disease at C4-5 level. He felt the patient might benefit from a cervical epidural steroid injection. It is not clear to me whether the patient ever had a cervical epidural injection for this. However, Dr. R suggested he may be a candidate for an ACDF at C4-5 and C5-6 if conservative measures failed to relieve his neck and right upper extremity symptoms. The patient was also evaluated by Dr. R for his lower back and right leg symptoms. Dr. R recommended that the patient have some lumbar epidural steroid injections or right-sided selective nerve root blocks. The patient did undergo a bilateral selective nerve root block with Dr. K on at least three different occasions, which only gave the patient a very temporary relief at the best lasting a week or so. Basically, the patient has been off work for the past year. Dr. N too him off work about a year ago placing him back on TTD status. In the interim, the patient has now applied for and has been accepted for social security disability. The patient admits that he would not be able to ever return back to his prior level of work duties required of him at Frito Lay. Apparently, he states he is still employed by Frito Lay technically. He has not yet been formally declared permanent and stationary from his recent exacerbation or new injury to his back, neck, and right shoulder. The patient has related to me that he prefers a more conservative form of treatment for his complaints. He has found chiropractic care helpful. He would like to consider surgical options as a very last resort, but would like have them remain open as part of his future medical care. It is my opinion and I would agree with the patient that if he thinks he can manage his situation on a conservative basis, this should be allowed to him. It is my opinion that I would declare the patient permanent and stationary at this point.
TOTAL TEMPORARY DISABILITY: Regarding total temporary disability, this patient has been off work for the past year, again, due to his subsequent injury of 03/29/1997. This patient should be allowed TTD benefits from the last date that he worked up until present.
PERMANENT AND STATIONARY STATUS: Regarding permanent and stationary status, I would consider the patient permanent and stationary as of today on 04/27/2005 with regards to his more recent industrial injury of 03/29/1997.
FACTORS FOR DISABILITY:
1. He has decreased cervical range of motion and lumbar trunk range of motion.
2. He exhibits disuse atrophy in the right shoulder girdle area and right biceps.
3. He exhibits diminished grip strength in the right upper extremity, which is his dominant arm per Jamar dynamometry.
4. He has an abnormal MRI of the cervical spine revealing disc protrusion at C5-6 on the right with multilevel degenerative disc disease and spondylosis. He also exhibits lumbar degenerative disc disease in the lumbar spine.
5. He has an abnormal MRI of the right shoulder revealing prominent impingement with tendonitis and tenosynovitis involving the supraspinatus and biceps tendons.
6. He has also had an abnormal nerve conduction study of the lower extremities suggesting a possible L5 radiculopathy on the right and the left by Dr. K.
1. Based on my evaluation of his neck pain complaints, it would be considered frequent and slight at rest.
2. Regarding his right shoulder pain complaints, it would considered frequent and slight at rest, increasing to a more moderate level with the use of the arm at or above shoulder height or repetitive pushing, pulling, lifting or torquing with the right upper extremity.
3. With regards to his lower back pain complaints, it would be considered constant and slight at rest. With activities of prolong sitting, standing, repetitive bending, stooping or lifting, it might increase it to a more moderate level of pain.
LOSS OF PRE-INJURY CAPACITY: With regards to the loss of pre-injury capacity, The patient relates that prior to his industrial injuries of 06/29/1994 as well as 03/29/1997, he was capable of repetitively bending and stooping. He could easily lift about 100 pounds. He states he now has difficulty performing these tasks. He cannot lift more than 10-15 pounds without aggravating his back, neck, or shoulder. He also states he could repetitively use his arm at or above shoulder height. He could push, or pull and lift at least 40-50 pounds without difficulty, now having difficulty lifting more than 5-10 pounds with the right upper extremity. He also relates having difficulty with sustained positions of neck gaze upward and downward as well as repetitive rotational movements of his neck, which he did not have prior to his industrial injuries. He states he difficulty with prolonged sitting or standing for more than 10-15 minutes at a time. He states prior to his industrial injuries as above, he could prolonged sit and stand for eight hours at a time without difficulty.
WORK RESTRICTIONS AND DISABILITY: With regards to work restrictions and disability, I would find it reasonable to place this patient in a disability category resulting in a limitation to a semi-sedentary work which contemplates the individual can do work approximately one-half the time in a sitting position and approximately one-half the time in a standing or walking position with the minimum of demands for physical efforts whether standing or walking. Basically, the patient should not be allowed or forced to sit for more than 15 minutes at a time and be allowed five minute interval change. He should not be allowed to stand for more than 15-20 minutes at a time and be allowed a five minute interval change in position. The patient should not repetitively bend or stoop, he should not lift more than 10-15 pounds maximally. He should avoid repetitive use of the right upper extremity at or above shoulder height and not repetitively push or pull or lift more than 10 pounds with the right upper extremity. He should avoid sustained positions of upward and downward gaze and repetitive motion movements of his neck.
CAUSATION AND APPORTIONMENT: With regards to issues of causation, this patient's history of injuries appear consistent with his above complaints relative to his industrial injury of 06/29/1994 as well as 03/29/1997. With regards to issues of apportionment, there are two separate industrial injuries it appears. There has been some suggestion that the second injury of 03/29/1997 was actually a flare-up or exacerbation of his old injury of 06/29/1994. There is no question that the second injury probably did flare up his injury complaints of 06/29/1994, but also in my opinion, this is a new injury that occurred on 03/29/1997. It is my opinion that there is some apportionment in this case. I would apportion at least 50% of his injury to his new injury of 03/29/1997. The remaining 50% would be apportionable to his pre-existing injury of 06/29/1994.
FUTURE MEDICAL CARE: Regarding future medical care, it is my opinion that future medical treatment should be allowed. The patient has in particular benefited from chiropractic care and Myox type muscle strengthening exercises for his neck, back, and shoulder pain complaints. Basically, he should be allowed 12-24 visits of chiropractic care per year to manage his industrial injury complaints. He should be allowed physical therapy for at 12-24 visits per year as well. The patient should be allowed access to analgesics, antiinflammatories, and muscle relaxers from time to time should he choose to use them. He should also be allowed surgical indication for his right shoulder, his neck, and lumbar spine should he change his mind about invasive procedures. Also, injection procedures such as steroid injections in his right shoulder for shoulder pain as well as epidural steroid injections in the cervical and lumbar spines should be considered an option for him if he should change his mind about these as well.
VOCATIONAL REHABILITATION: Regarding vocational rehabilitation, the patient is a qualified injured worker in my opinion. He is currently on social security disability. If the patient should choose to re-enter the work force, he should be allowed access to vocational retraining to do so.
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