History of anorexia nervosa.
History of polysubstance dependence in controlled environment (marijuana,cocaine inhalation, alcohol).
History of personality disorder with antisocial obsessive borderline traits.
Status post lumbar diskectomy and fusion, 2/17/99.
Large herniated left disc protrusion, probably herniated nucleus pulposus L5-S1; two small disc protrusions from L2-3 to L4-5 (MRI 9/3/98).
Mild degenerative disease L3-4, L4-5 with mild disc space narrowing and sclerosis without evidence of acute fracture or spondylolisthesis with moderate rotary scoliosis, slightly more severe on 6/15/98 (x-rays 1993, 9/24/97, 6/15/98).
History of chronic lower back pain syndrome with left L5-S1 radiculopathy since 1993.
History of bipolar disorder with modulation from depression to mixed hypomania, treated with Zoloft, Depakote, Mellaril, Ativan and Vistaril.
Status post surgery for deviated septum.
History of hay fever.
History of penicillin and codeine allergy.
Pyuria (urinalysis 9/17/97).
Upper respiratory infection, 10/30/97.
Contusions back, left leg and possible right lower back strain, 5/18/98.
Scrape of the bottom of the left foot, 5/27/98.
Back pain, 5/29/98.
Possible urinary tract infection, 6/7/98.
Lumbar spondylosis or sciatica, rule out intervertebral disc, 6/19/98.
Possible dizziness, rule out eating disorder, 7/5/98.
Possible seizure/fall, 7/18/98.
Severe back pains with leg spasms and inability to walk ,7/22/98.
Small skin abrasion left foot, 9/18/98, 9/19/98.
Gross tremors, 9/21/98, 10/9/98.
Left foot ulcer, 11/27/98.
Small bruise reaction right foot, 12/10/98, and mild foot sprain 12/11/98.
Flu symptoms/cold, 12/23/98.
History of physical abuse by mother, sexual abuse as a child and physically abusive adult relationships.
History of partial deafness in one ear, almost completely (80% in the other).
Medical records from 7/12/97 through 3/18/98 were reviewed and indicated the
examinee, currentlya 24 year old female, is confined at the Department of
currentlya 24 year old female, is confined at the Department of
Corrections with a sentence of 15-17 years for four counts of lewd and lascivious
behavior with a child and on 2/17/99 had lumbar diskectomy and fusion as
treatment for a large left disc protrusion (herniated nucleus pulposus) L5-S1 with
associated small disc protrusions from L2-3to L4-5 (MRI 9/3/98) with concurrent
history of chronic lower back pain syndrome with left L5-S1 radiculopathy
beginning in 1993 with progressive decompensation since first seeking Emergency
Room evaluation on 10/17/97 for back symptoms which, at that time, were felt to be
secondary to lumbosacral degenerative disc disease and an obvious chronic
deformity in the pelvic area.
Prior to confinement at the Department of Corrections the examinee had a history of anorexia nervosa, polysubstance dependence in a controlled environment (marijuana, cocaine inhalation, alcohol), personality disorder with antisocial obsessive borderline traits, history of physical abuse by her mother, sexual abuse as a child and physically abusive adult relationships and notes (8/31/98, Ingram) having partial deafness in one ear and almost completely (80%) in the other. Moreover, the examinee is presently being treated for a bipolar disorder with modulation from depression to mixed hypomania, treated with various medications which have included Depakote, Mellaril, Ativan and Vistaril.
Throughout her confinement at the Department of Corrections, the examinee has had mental health sessions approximately biweekly and, for the most part, has been stable with difficulty sleeping, fluctuations in weight and periodic side effects from medications.
Also, during confinement at the Department of Corrections, the examinee has had an annual upper respiratory infection though the majority of her visits to the Emergency Room were apparently a consequence of her symptoms of chronic low back syndrome with left lumbar radiculopathy, eventually culminating in lumbar diskectomy and fusion on 2/17/99. The single incident of a possible seizure/fall (7/18/98) with incontinence is as yet not completely understood in the context of her condition though may have been a side effect of medication or result of increased pain.
The examinee was also treated for acne.
As a consequence of an underlying chronic lower back condition, prior to lumbar diskectomy and fusion on 2/17/99, the examinee was progressively unable to maintain her culinary work activities, comfortably lift, push, pull, stand or walk and periodically would have to sit down to relieve discomfort or squat during prolonged standing. The examinee also required a bottom bunk, double mattress, low bunk, special shoes, anti-inflammatory and muscle relaxant medications and bed rest.
Subsequent to lumbar diskectomy and fusion on 2/17/99, as of 3/15/99, the examinee noted her back was much better than during the previous five years, and this has had a significantly positive effect on her moods (3/15/99). On 3/18/99 Dr. M.D., psychiatrist, noted the examinee’s mental status was stable, mood good, and she was recovering well from back surgery and medications were effective without side effects.
PERMANENT FUNCTIONAL IMPAIRMENT RATING BASED ON THE AMA GUIDES TO THE EVALUATION OF PERMANENT IMPAIRMENT, 4TH EDITION:
When combined and rounded to the nearest value of 0-5, this examinee has a permanent injury with a permanent functional impairment rating of 10% to the body as a whole as a consequence of her chronic low back syndrome with left lumbar radiculopathy for which she was treated with lumbar diskectomy and fusion on 2/17/99.
MEDICAL OPINION WITH REGARD TO MEDICAL RECORDS CASE REVIEW
With a greater than 50% degree of medical certainty this examinee’s post surgical low back syndrome in conjunction with her psychiatric predisposition will have the effect of requiring modification of the examinee’s daily activities.
In my opinion, by review of medical records only, theexaminee should
maintain a daily stretching and strengthening exercise program including ball rolling
and Thera-Band stretching in conjunction with progressive musculoskeletal
rehabilitation to facilitate increased flexibility and strength. Should the examinee
facilitate increased flexibility and strength. Should the examinee
physically stressful activities.
develop an acute exacerbation, she may benefit from modalities of physical
exacerbation, she may benefit from modalities of physical
therapy, hydrotherapy (swimming), neuromuscular massage, TENS unit,
(swimming), neuromuscular massage, TENS unit,
anti-inflammatories, muscle relaxants and psychotropic medication as needed to
diminish pain, extend flexibility and improve function. Moreover,
flexibility and improve function. Moreover,
anesthetic/cortisone trigger point and/or paravertebral injections may have
and/or paravertebral injections may have
therapeutic benefit. The examinee should sleep on a firm mattress, use a lumbar
support cushion and consider a lumbosacral support when engaging in any type of
physically stressful activities.
With regard to the examinee’s psychiatric history of cyclothymia, anorexia nervosa, polysubstance dependency, personality disorder, bipolar disorder and history of physical and sexual abuse, she should continue with psychiatric management and treatment which may require ongoing medication, counseling and individual and group psychotherapy.
With regard to the examinee’s history of a possible seizure, should she develop recurrent symptoms, an EEG, blood tests including but not limited to complete blood count and chemistry profile, urinalysis, MRI of the brain and neurologic consultation would be recommended.
With regard to the examinee’s history of partial deafness in one ear almost completely (80%) in the other, an audiometric and tympanometric study in conjunction with an evaluation by an otolaryngologist would be recommended.
walking or climbing and any and all other activities which may aggravate her underlying condition. A functional capacity evaluation may be useful in
underlying condition. A functional capacity evaluation may be useful in
This medical evaluation was based solely on the medical records reviewed from 7/12/97 through 3/18/99.
Review of additional medical records, a personal medical history and physical examination may have the effect of modifying the aforementioned conclusions and recommendations.
THE HEALTH PLACEA Private Medical Practice of David P. Kalin, M.D., M.P.H.Tel 813.966.1431 Fax 813.925.1932
WE ARE HERE