In my opinion, by review of medical records, history and physical examination this patient’s present condition is the result of the slip injury of 6/9/97.
The patient had a history of infantile poliomyelitis with residual atrophy of the right leg and foot and had two subsequent work related fractures of the right leg, the first in 1991 in which he had a fracture of the femur which was surgically pinned with eventual removal of pins from which the patient received a 15% permanent functional impairment rating. The second fracture was of the proximal tibia in 1996 after which he was feeling weaker in the right leg and overall 75% improved prior to the slip injury of 6/9/97.
The slip injury of 6/9/97 caused the patient’s post traumatic pain as a consequence of chronic post traumatic myofasciitis of the metatarsal phalangeal joint of the left great toe and, as a consequence, has caused compromise of the blood supply of the left great toe facilitating the development of nail dystrophy from onychomycosis, a fungal infection, which has proceeded to involve the other toes of the left and right foot and requires oral antifungal treatment for a minimum of 3 months.
Contradictory opinions with regard to a fracture of the left great toe have no direct bearing on the final aforementioned conclusion as the patient had documented damage to the left first distal extremity (emergency room record 6/12/97).
The patient has been advised of the permanent nature of his injury and of having achieved maximum medical improvement. The
patient is encouraged to obtain Lamisil 250 mg prescribed daily for a minimum of 3 months with serial review of liver enzymes done on a monthly basis. The patient should also continue using soft soled and high backed shoes and/or sandals as well as padding around the left great toe and use anti-inflammatories as needed to diminish pain. The patient may also benefit from the interdigital application of over the counter antifungal creams.
Moreover, the patient is advised of the propensity for chronic fungal infection should the patient not maintain appropriate treatment. The patient should use a cane as needed and should he develop an acute exacerbation he should seek modalities of physical therapy and consider additional anesthetic/cortisone joint injections. The patient may also benefit by a reevaluation from a podiatrist, with regard to removal of the left great toenail. Marginal medical improvement may be achieved with the recommendations of the podiatrist with regard to nail removal of the left great toe and treatment with antifungal medication.. The patient should follow up with a medical evaluation with regard to high cholesterol and a urologic evaluation with regard to blood noted in the urine (10/15/98).
PHYSICAL LIMITATIONS AND RESTRICTIONS:
The patient should avoid walking further than 100-200 feet, occasionally may need to use a cane and should avoid any and all other activities that may aggravate the underlying condition caused by the slip injury of 6/9/97.
Should the patient’s symptoms persist or worsen he should seek medical reevaluation.
THE HEALTH PLACEA Private Medical Practice of David P. Kalin, M.D., M.P.H.Tel 813.966.1431 Fax 813.925.1932
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