MEDICAL EVALUATION AS A BASIS FOR REDUCTION OF PRISON TERM

DIAGNOSES:

• Cyclothymia.

• 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.

• Acne, 9/23/98.

• 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).   

CONCLUSION:            

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 

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.

RECOMMENDATIONS: 

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 

physically stressful activities.

develop an acute exacerbation, she may benefit from modalities of physical 

therapy, hydrotherapy (swimming), neuromuscular massage, TENS unit, 

anti-inflammatories, muscle relaxants and psychotropic medication as needed to 

diminish pain, extend flexibility and improve function. Moreover, 

anesthetic/cortisone trigger point 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.

PHYSICAL LIMITATIONS AND RESTRICTIONS: 

The examinee should avoid lifting greater than 10pounds, repetitive bending, twisting,squatting, prolonged standing or sitting for longer than 30-60 minutes, extended walking or climbing and any and all other activities which may aggravate her underlying condition.  A functional capacity evaluation may be useful indetermining the examinee’s specific physical limitations and restrictions.  

POSSIBLE FUTURE DIAGNOSTIC STUDIES:  

Should the examinee’s symptoms of low back pain and left lumbar radiculopathy persist, she should seek orthopaedic and/or neurosurgical reevaluation at which time a repeat MRI of the lumbosacral spine and neurodiagnostic studies of the left lower extremity including NCV, EMG and SSEP should be considered.

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 PLACE
A Private Medical Practice of David P. Kalin, M.D., M.P.H.
Tel  813.966.1431  Fax 813.925.1932