INDEPENDENT MEDICAL EVALUATION, WORK RELATED INJURY WITH PRE-EXISTING CONDITION
PERMANENT FUNCTIONAL IMPAIRMENT RATING BASED ON THE 1996 FLORIDA UNIFORM PERMANENT IMPAIRMENT RATING SCHEDULE :
This patient has a permanent injury resulting in a functional impairment rating of 5% to the body as a whole, secondary to injuries from the abovementioned work related injury of 2/4/97.
In my opinion this patient’s present condition is the result of progressive aggravation of a preexisting condition subsequent to the return to work on 08/09/96 with a prominent traumatic effect being one day of excessive work during November 1996 (work related injury of 2/4/97), all of which have aggravated the patient’s underlying condition which manifested prior to 1990 with low-grade low back pain, presumably from scoliosis followed by a motor vehicle accident of 06/04/90 and 07/20/92 which resulted in chronic cervical and lumbosacral strain and left cervical and lumbar radiculitis with chronic myofascial pain syndrome.
This condition, in turn, had been exacerbated and/or aggravated by the work related injury on 04/17/95.
The ongoing inability to adapt to the work environment has aggravated the patient’s pre-existing psychological predisposition which in conjunction with the dissonance of medical opinions since 1996 with regard to the patient’s physical limitations and restrictions has, within reasonable medical probability, contributed to the patient’s progressive dysthymia.
By review of available medical records, history and physical examination, the patient has, according to the AMA GUIDES TO THE EVALUATION OF PERMANENT IMPAIRMENT, FOURTH EDITION, an additional apportioned permanent functional impairment rating of 10% from the effects of the motor vehicle accident of 6/04/90 and 5% from the effects of the motor vehicle accident of 7/20/92.
The patient has been advised of the permanent nature of her injury and of having achieved maximum medical improvement.
The patient is encouraged to continue with daily neck and back stretching exercises and is instructed should she develop an acute exacerbation to seek modalities of physical therapy, hydrotherapy, osteopathic and/or chiropractic manipulation, massage, use a TENS unit and take anti-inflammatories, muscle relaxants and/or pain medications as needed to diminish pain and extend
flexibility. The patient may also benefit from using a cervical pillow, lumbosacral cushion and lumbosacral support. The patient has been advised of the potential therapeutic benefit of
anesthetic/cortisone paravertebral and epidural steroid injections, as wel1 as prolotherapy treatments. The patient is encouraged to swim regularly, if able. The patient should also follow up with psychological counseling.
Moreover, the patient should follow up with coordinated treatment from a health care provider specializing in chronic pain management and familiar with post traumatic myofascial pain and fibromyalgia syndromes.
The patient has been advised of the opinion of Dr. M.D., Neurosurgeon, (7/20/91) with regard to the motor vehicle accident of 6/4/90 that she developed chronic myofascial pain syndrome of the cervical and lumbar spine for which she was not a surgical candidate and was recommended conservative care with symptomatic treatment, physical therapy modalities, pain management, biofeedback and epidural block.
The patient has been advised of the opinion of Dr. M.D., (2/16/93) of having sustained a permanent functional impairment rating of 15% to the body as a whole secondary to injuries from the motor vehicle accident of 7/20/92; a previous accident affected C5-6 and the second accident aggravated the symptoms of the first accident and caused additional permanent problems which would require intermittent physical therapy treatments, anti-inflammatories, exercises and possible osteopathic manipulation.
The patient has been advised of the opinion of Dr. D.O. (5/04/93) with regard to the motor vehicle accident of 07/20/92 that she sustained a permanent injury with a partial permanent impairment rating, according to the AMA Guidelines, of 19% to the body as a whole as a consequence of chronic cervical, thoracic and lumbosacral strain.
The patient has been advised of the opinion of Dr. M.D., physical medicine, rehabilitation, (4/9/96) with regard
to the work related injury of 4/17/95 that she had an aggravation of a preexisting chronic pain problem without clear objective evidence for physiologic injury for which an impairment rating was indicated according to 1993 Florida Impairment Rating Guide and had no physical restrictions.
The patient has been advised of the opinion of Dr. D.O., (12/l0/96) that because of chronic and recurring musculoskeletal symptoms with chronic strain of the cervical and lumbar spine associated with radiculitis and sciatic neuralgia related to a previous injury sustained in 1992 that despite intermittent periods of improvement which had allowed the patient to return to work, she continued to have physical limitations and restrictions as her symptoms tended to recur and require intermittent therapy for which the following work restrictions were then established: continuous standing or walking limited to 2 hours at a time with a break in between, total amount of working time during an 8 hour day should be between 2 to 4 hours, limit
continuous sitting to 2 to 4 hours per day per 8 hour work shift with a total of 4 to 6 hours total time during the day, may drive a car or truck, lifting limited to 10 lb., refrain from doing any lifting, ab1e to use hands for simple grasping and fine manipulation, restricted from any heavy pulling, any repetitive or prolonged bending, squatting or climbing, knee1ing or reaching, recommend sedentary work which cou1d be of a clerical or secretarial position. Dr. also noted, due to the recurring nature of her symptoms, the patient would at times be required to take various medications such as nonsteroidal anti-inflammatory drugs, muscle relaxants and analgesics.
The patient has been advised of the opinion of Dr. M.D., orthopaedic surgeon, (3/17/97) with regard to prior injuries that he was unable to identify any objective clinical finding that could substantiate the patient’s extensive and diffuse symptomatology though she probably sustained evidence of a mild back strain in her muscles when she apparently engaged in the classroom’s chairs and desks with regard to the work
related injury of 2/4/97.
The patient has been advised of the opinion of Dr. Ph.D., psychologist, (8/27/97) that the patient’s major depressive disorder is an agitated irritated type, long standing and probably going back well into her past, perhaps to her childhood or adolescence and that the more recent adjustment disorder is a reaction to her medical problems and poses vocational and functional limitations, including a very limited ability to
learn new information, diminished energy to go to school or work, tendency to withdraw under stress which would interfere with ability to communicate with supervisors and co-workers. Dr. PhD. noted the current condition would probably not change a great deal without medication and/or treatment and that the prognosis was fair with treatment and poor without; he recommended the patient be involved in mental health treatment, continue with counseling, receive stress management and relaxation training and be referred to a psychiatrist for review of previous medications and the need for the aforementioned treatment.
The patient has been advised of the opinion of Dr. M.D., physical medicine, rehabilitation, (12/2/97) with regard to the work related injury of 4/17/95 that she had reached maximum medical improvement on 5/20/97 and had a permanent functional impairment rating of 3% according to the Florida Impairment Rating Guide, Edition 1993, with the following physical restrictions: 8-hour day, sit 8 hours intermittently, stand 4-6 hours intermittently, walk 4-6
hours intermittently, lift 21-50 occasionally, up to 10 pounds frequently, 11-20 pounds frequently, carry up to 10, 11-20 pounds frequently, 21-50 pounds occasionally, bend frequently, squat occasionally, reach above shoulder level
continuously, right hand dominant, simple grasping, pushing/pulling, left hand simple grasping, pushing/pulling, feet for repetitive movements, restrictions of activities involving unprotected heights, being around moving machinery,
exposure to marked changes in temperature and humidity, driving automatic equipment.
The patient has been advised of the opinion of Dr. M.D., psychiatrist, (9/9/98) that her present mental state is a reflection of her lifelong marginal emotional adaptation which constitutes a personality disorder and is not related to her physical injuries nor the result of the claims of 4/17/95 or 2/4/97, and she will continue to need emotional support and psychiatric treatment.
The patient has been advised of the opinion of Dr. M.D., psychiatrist, (9/16/98) of her chronically unstable nature, especially over the last 20-30 years, and that her psychiatric
difficulties do not appear to be related to her industrial accidents of either 4/17/95 or 2/4/97 though she should continue to acquire support from various community resources.
The patient has been advised of the opinion of Dr. M.D., (3/9/99) that she suffers from myofascial pain syndrome and has reached maximum medical improvement, and she is unlikely to benefit from any further interventions, should return to work full time, full duty without restrictions, participate inan exercise program and take Celebrex and Ultram with medical follow up as needed.
The patient should avoid continuous standing or walking for longer than 15-20 minutes without a break with total amount of walking time during an eight hour day between one to two hours, no sitting for longer than one to two hours per eight hour shift with a total of two to four hours total time during the day, should not be allowed to drive a car or truck, lift greater than one to two pounds or do repetitive lifting. The patient should also avoid pulling but may do simple grasping and fine manipulation. Moreover, the patient is restricted from any prolonged or repetitive bending, squatting or climbing, kneeling or reaching.
The patient should continue with her efforts at the Bureau of Vocational
Rehabilitation and is recommended to have a repeat functional capacity
evaluation prior to any return to work.
Should the patient’s condition significantly worsen, she should again seek medical reevaluation.
THE HEALTH PLACE A Private Medical Practice of David P. Kalin, M.D., M.P.H.Tel 813.966.1431 Fax 813.925.1932
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