Download tb1-122416a

Transcriptionist: Tamara K. Bobb
Date: 12/24/2016
tb1-122416a
Patient Name
Harper, Sandra
Harper, Sandra
McCutcheon, Nancy
Davis, Nolan
Davis, Nolan
Davis, Nolan
Davis, Nolan
Martinez, Pablo
Martinez, Pablo
System #
7926
7927
7928
7929
7930
7931
7932
7933
7934
Doc Type
Progress Note
Incomplete
Progress Note
Initial Visit
Progress Note
Progress Note
Progress Note
Initial Visit
Progress Note
Doctor
Estivo
Estivo
Estivo
Estivo
Estivo
Estivo
Estivo
Estivo
Estivo
HARPER, SANDRA
12/21/2016
CURRENT STATUS: The patient is following up with me after undergoing an MRI of the
cervical spine on 12/05/2016. The MRI is here for my review. There are protruding
degenerative disks throughout the cervical spine, particularly at C7-T1, with some narrowing of
the neural foramina along the left side. There is congenital partial fusion at C5-6. No other
abnormalities are appreciated.
Today the patient states she is continuing to have cervical spine pain. She denies any upper
extremity symptoms. She denies any pain, numbness or weakness to the upper extremities. She
sees a neurologist for her headaches.
PHYSICAL EXAMINATION: The cervical spine reveals full rotation to the right and left.
There is some discomfort with rotation to the right and left. There is some discomfort with
extension and flexion. Negative Spurling's. Deep tendon reflexes are +2/4 with the biceps,
triceps and brachioradialis, +5/5 strength with the biceps, triceps and brachioradialis bilaterally.
The full neurovascular status is intact with both upper extremities. Full range of motion of both
shoulders, both elbows and both wrists without discomfort. She has good grip strength to both
hands today. The thoracic and lumbar spines are nontender. Negative straight leg raising
bilaterally. Deep tendon reflexes are +2/4 with the patella and Achilles, +5/5 strength with hip
and knee flexors and extensors, +5/5 strength with plantar flexion and dorsiflexion strength to
both ankles today. She is able to toe walk and heel walk. She ambulates with a normal gait.
IMPRESSIONS AFTER EXAMINATION:
1.
Cervical spine strain related to the injury claim of 11/20/2015.
2.
Preexisting age related degenerative disk disease throughout the cervical spine
with congenital partial fusion at C5-6.
SUMMARY AND RECOMMENDATIONS: I would relate the cervical spine strain to the
incident that occurred at work on 11/20/2015. I would recommend physical therapy for the
treatment of the cervical spine strain. We will have her working with the therapist three times a
week for the next month. She tells me that she does benefit from over-the-counter Aleve. She is
to take Aleve as directed and as tolerated over-the-counter. She is allowed to be working with
the temporary restriction of occasional overhead work. I have answered all of her and the
Medical Case Manager’s questions to their satisfaction today. I will see her back in one month.
Time required was 25 minutes.
John P. Estivo, D.O.
JPE/tkb
cc:
Kansas State Insurance Fund
Medical Case Manager Karen Hamilton, RN with CompAlliance
HARPER, SANDRA
11/22/2016
This 66-year-old female presents today for an Independent Medical Evaluation in relation to the
injury claim of 11/20/2015. I have explained to the patient that she is being seen today for
evaluation only and that there is no physician/patient relationship being established. She states
she understands this.
CHIEF COMPLAINT: 1. Cervical spine pain. 2. Headaches.
HISTORY OF CHIEF COMPLAINT: This 66-year-old female works for Ft. Hays State
University as a custodian. She states that on 11/20/2015 she was closing an overhead window
when the overhead window struck her on the top of her head. She denies any loss of
consciousness. She states she was knocked to the floor. She states she did have a bump on her
head. She reported the incident and was sent on for treatment.
REVIEW OF MEDICAL RECORDS: The patient was seen at Hays Family Medicine on
11/24/2015. She presented complaining of headaches she related to an incident occurring at
work on 07/20/2015, at which time a window struck her in the top of her head. She reported she
had occasional dizzy spells as well as headaches and lightheadedness. She was also complaining
of neck pain and fatigue as well as drowsiness. The patient was examined and diagnosed with a
concussion. S he was prescribed medications.
The patient followed up on 11/30/2015, continuing to complain of headaches as well as neck
pain. She was sent on for a CT scan of her head.
A CT scan of the head was completed on 11/30/2015, revealing no acute abnormalities.
The patient was seen on 12/07/2015 ________
Dictation ended.
John P. Estivo, D.O.
JPE/tkb
MCCUTCHEON, NANCY
12/22/2016
CURRENT STATUS: The patient is following up with me complaining of right groin pain. She
states it started about three days ago. She denies any new injury. She tells me she has had to
switch back to using the walker from the use of the quad cane. She tells me that they have been
advancing her exercises in physical therapy, but she seemed to be tolerating that well while those
exercises were being done last week. She does not recall anything specifically happening when
her pain in her groin suddenly started about three days ago. She denies any sternum pain or left
rib pain. She is telling me the left side of her pelvis is feeling better. She is denying any pain
radiating into the lower extremities. She denies any lumbar spine pain today. She states she still
does have some numbness and tingling into both of her hands, but it seems to be a little less since
she had not been using the walker. She does not believe there has been any increase in the
numbness with the recent use of the walker over the last few days.
PHYSICAL EXAMINATION: The cervical spine reveals full range of motion without
discomfort. No muscle spasm. No guarding. Deep tendon reflexes are +2/4 with the biceps,
triceps and brachioradialis, +5/5 strength with the biceps, triceps and brachioradialis bilaterally.
There is some numbness and tingling along the median nerve distribution of both hands today.
There is muscle wasting noted to both of her hands. The thoracic spine is nontender. The
lumbar spine is nontender. The pelvis is tender along the right side, extending across to the right
pubis. The left side of the pelvis is nontender today. There is some discomfort to the sacrum to
palpation favoring the right side. Negative straight leg raising bilaterally. Deep tendon reflexes
are +2/4 with the patella and Achilles, +5/5 strength with hip and knee flexors and extensors,
+5/5 strength with plantar flexion and dorsiflexion strength to both ankles. She is able to stand
on her toes and stand on her heels. I had her ambulate up and down a hallway today without the
walker. She is able to weight bear on both of her legs without any right groin pain, but as she
flexes her right hip she does experience right groin pain. There is no pain with passive range of
motion of the right hip joint. There is discomfort to the right hip joint with active range of
motion. The right knee and right ankle are nontender. There is a significant valgus angulation to
the right knee due to her advanced arthritis. The left knee reveals significant valgus angulation as
well, consistent with degenerative joint disease. There is no left hip or left ankle pain throughout
range of motion today, actively or passively.
X-rays of the right hip were ordered, taken and reviewed today, AP and lateral views, revealing
no fractures to the right hip. The femoral head and neck appear to be intact. No displaced
fractures are appreciated. There is evidence of the healing pubic ramus fractures on the right
side. No other abnormalities are seen.
X-rays of the sternum were ordered, taken and reviewed today, AP and lateral views, revealing
the sternal fracture to remain nondisplaced. It appears to be healing well.
X-rays of the left ribs were ordered, taken and reviewed today, two views of the left ribs,
revealing the left third rib fracture to be healing well.
John P. Estivo, D.O.
12/22/2016
MCCUTCHEON, NANCY
Page 2 of 2
X-rays of the lumbar spine were ordered, taken and reviewed today, AP and lateral views,
revealing evidence of the kyphoplasty at L4. There are degenerative changes seen throughout
the lumbar spine.
X-rays of the sacrum were ordered, taken and reviewed today, AP and lateral views, revealing
the right sided sacral fractures to remain nondisplaced. They appear to be healing well.
X-ray of the pelvis was ordered, taken and reviewed today, an AP view, revealing the pelvis
fractures to be healing well. They are currently in acceptable alignment.
IMPRESSIONS AFTER EXAMINATION:
1.
Status post L4 kyphoplasty.
2.
Right sided pubic ramus fractures.
3.
Right sided sacral fractures.
4.
Sternal fracture.
5.
Left third rib fracture.
6.
Right hip pain.
RECOMMENDATIONS: I would recommend the patient undergo an MRI of her right hip to
further evaluate her right hip pain. We will allow her to continue to use her walker. We will
keep her with the same temporary restrictions of seated work only. She is to have close parking.
She is to work a six hour work day. All of her questions were answered to her satisfaction.
Total time required was 30 minutes. I will reevaluate her after the MRI of the right hip has been
completed.
John P. Estivo, D.O.
JPE/tkb
cc:
Senior Medical Case Manager Pamela Eslinger, RN
Broadspire
Cessna Health Services
DAVIS, NOLAN
06/02/2016
CHIEF COMPLAINT: 1. Cervical spine pain with occasional right upper extremity pain. 2.
Lumbar spine pain with right and left buttocks pain.
HISTORY OF CHIEF COMPLAINT: This 41-year-old male states that he works for Hammel
Scale Company, calibrating scales that are used to weigh trucks at a grain elevator. He tells me
that on 03/23/2016 he was repetitively lifting 50 pound weights. He tells me he lifted up to
20,000 pounds in one day. He tells me he began experiencing cervical spine pain radiating into
the left arm as well as lumbar spine pain radiating into the right and left buttocks on that day. He
tells me he reported the symptoms to his employer. He then went on to see his family physician.
He then underwent treatment through occupational medicine.
REVIEW OF MEDICAL RECORDS: The patient was seen by Dr. Barclay on 03/30/2016. He
was complaining of neck and left shoulder pain as well as lower back pain. He reported that he
had fallen about 20 feet, landing on his lower back about a year and a half to two years ago.
After being examined, he was diagnosed with neck pain and back pain. He was prescribed
prednisone and Tizanidine.
He followed up with Dr. Barclay on 05/16/2016 for recheck on his neck and lower back pain.
He reported on that day that the onset of his symptoms were some time around 03/23/2016 when
he was at work, lifting heavy items while unloading a truck. He reported that since that time he
was experiencing pain to the back of his neck, extending toward the left trapezius and down
toward the right triceps. He was also complaining of lower back pain. After being examined, he
was diagnosed with: 1. Cervical radiculopathy. 2. Low back pain with radicular pain. It was
recommended that he undergo an MRI of his cervical spine as well as an MRI of his lumbar
spine. He was continued on medications.
The patient was seen at Via Christi Occupational and Environmental Medicine on 05/20/2016.
He presented there for a second opinion. He was then diagnosed with: 1. Low back pain. 2.
Cervical spine pain with left arm radiculopathy. He was given temporary work restrictions.
Additional records were to be obtained from his primary care physician.
REVIEW OF MEDICAL RECORDS PRIOR TO THE INJURY CLAIM OF 03/23/2016: The
patient was seen by his family physician, Dr. Barclay, on 09/10/2010. He was diagnosed with
chronic low back pain. X-rays were ordered of his lumbar spine.
MRI of the lumbar spine was completed on 10/14/2010. The reason for the lumbar spine MRI
was stated to be low back pain. The MRI revealed degenerative bulging disks at L4-5 and L5S1. the bulging disk at L5-S1 was favoring the right side, abutting the right S1 nerve root.
There are past medical records documenting my treatment of this patient in relation to an injury
claim of 06/02/2012. He was initially seen in my office on 06/13/2012 in relation to that injury
claim. This was an injury that occurred while working for Hammel Scale Company. He
reported that on 06/02/2012 he was climbing down a 12 foot ladder. He reported that he had
John P. Estivo, D.O.
06/02/2016
DAVIS, NOLAN
Page 2 of 4
REVIEW OF MEDICAL RECORDS (continued):
fallen about 6 feet down to the ground. He was reporting experiencing neck pain and lower back
pain as well as right hand pain. On that day, he did give me a history of a previous injury
occurring in 2003 while working for National Plastics. He described an injury to his right ribs.
He denied any previous injury to his cervical spine, lumbar spine or right wrist prior to the fall
that occurred on 06/02/2012. During his treatment for the injury claim of 06/02/2012, he
underwent MRIs of his cervical and lumbar spines.
MRI of the cervical spine, completed on 06/05/2012, revealed age related degenerative changes
throughout the cervical spine. No acute abnormalities.
MRI of the lumbar spine was completed on 06/15/2012, revealing a bulging disk at L5-S1.
The patient underwent an MR arthrogram of the right wrist on 06/15/2012, revealing no
abnormalities.
A CT scan of the lumbar spine was completed on 06/13/2012, revealing a bulging disk at L5-S1.
No other abnormalities.
A CT scan of the head, completed on 06/13/2012, revealed no abnormalities.
A CT scan of the cervical spine, completed on 06/13/2012, revealed no abnormalities.
He was treated in my office for a cervical spine strain, a lumbar spine strain and a right wrist
sprain. He was found to be at maximum medical improvement on 08/06/2012. The cervical and
lumbar strains had resolved. The right wrist sprain was resolving. He was released without
restrictions. He was given a 0% impairment according to the Fourth Edition of the AMA Guides
to the Evaluation of Permanent Impairment, in relation to the injury claim of 06/02/2012.
The patient was seen by his family physician, Dr. Barclay, on 10/03/2014. He presented
complaining of left sided neck pain extending toward the left shoulder with decreased range of
motion to his neck. He reported that this started about one month ago. He denied any injury.
After being examined, he was diagnosed with cervicalgia. He was prescribed cyclobenzaprine
and naproxen.
PAST MEDICAL HISTORY: The patient has a history of previous cervical and lumbar spine
strains as well as degenerative disk disease to the cervical and lumbar spines.
The patient denies any heart disease, lung disease, diabetes, hepatitis, ulcers or kidney disease.
PAST SURGERIES: None.
MEDICATIONS: He is currently taking ibuprofen, cyclobenzaprine and hydrocodone.
John P. Estivo, D.O.
06/02/2016
DAVIS, NOLAN
Page 3 of 4
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He states he is single. He denies any alcohol use. He smokes cigarettes
on a daily basis. He denies any drug use.
REVIEW OF SYSTEMS: Eyes: Negative. Respiratory: Negative. Genitourinary:
Cardiovascular:
Negative.
Gastrointestinal:
Negative.
Psychiatric:
Musculoskeletal: He has had previous cervical and lumbar spine strains. He has a
degenerative disk disease to the cervical and lumbar spines. Neurological: He
numbness and tingling sensations into his extremities occasionally.
Negative.
Negative.
history of
admits to
PHYSICAL EXAMINATION: Reveals a 41-year-old male. He is 5 feet 11 inches tall. He
weighs 220 pounds. He is right hand dominant. The cervical spine reveals some tenderness
throughout range of motion along the left side. There is tenderness to palpation along the left
side of the cervical spine. Negative Spurling's. Deep tendon reflexes are +2/4 with the biceps,
triceps and brachioradialis, +5/5 strength with the biceps, triceps and brachioradialis bilaterally.
The full neurovascular status is intact with both upper extremities. The right and left shoulders
have full range of motion without discomfort. Negative drop arm, negative Yergason, negative
apprehension sign, negative Hawkins, negative Speed's and negative O'Brien. No instability.
Full range of motion of both elbows and both wrists without discomfort. He has good grip
strength to both hands today. The thoracic spine is nontender. The lumbar spine reveals some
discomfort to palpation. There is some tenderness throughout range of motion of the lumbar
spine. Negative straight leg raising bilaterally. Deep tendon reflexes are +2/4 with the patella
and Achilles, +5/5 strength with hip and knee flexors and extensors, +5/5 strength with plantar
flexion and dorsiflexion strength to both ankles today. He is able to toe walk and heel walk.
Full range of motion of both hips, both knees and both ankles without any pain to those joints.
He has a normal, smooth gait today.
X-rays of the cervical spine were ordered, taken and reviewed today, AP and lateral views as
well as two oblique views and an odontoid view, including flexion and extension views,
revealing no fractures, no subluxation, no dislocation and no acute abnormalities seen.
X-rays of the lumbar spine were ordered, taken and reviewed today, AP and lateral views as well
as two oblique views of the spine and a spot lateral at L5-S1, including flexion and extension
views, revealing no fractures, no subluxation, no dislocation and no acute abnormalities seen.
No signs of any instability.
IMPRESSIONS AFTER EXAMINATION:
1.
Cervical spine pain.
2.
Lumbar spine pain.
John P. Estivo, D.O.
06/02/2016
DAVIS, NOLAN
Page 4 of 4
SUMMARY AND RECOMMENDATIONS: This patient does have a history of previous
cervical spine and lumbar spine injuries. I treated him in 2012 for an injury claim of 06/02/2012
for strains to his cervical and lumbar spines. Those strains resolved as of my last evaluation of
him on 08/06/2012. It does appear that he did go on to see his family physician for a similar
strain to his neck in 2014, but I have no further documentation to indicate that went on to be a
long term problem. He tells me he had complete resolution of his neck pain at that time. He tells
me he was not having any cervical or lumbar spine pain prior to the incident of 03/23/2016.
When the mechanism of injury is taken into consideration, I think it is reasonable that he could
have injured his cervical spine and his lumbar spine on 03/23/2016. The prevailing factor and
need for medical treatment regarding this patient's cervical and lumbar spine complaints would
be the incident of 03/23/2016. I would recommend temporary restrictions of no more than 20
pounds to be lifted. He can perform occasional overhead work. I would recommend he
discontinue the hydrocodone. He should stay off of narcotics at this time. He is placed on
cyclobenzaprine as a muscle relaxant, 10 mg, one p.o. q. h.s. for the next two weeks, and 15
tablets were dispensed to him today along with instructions. He is placed on meloxicam as an
anti-inflammatory medication, 7.5 mg, one p.o. b.i.d. with food. He is given GI warnings about
this medication and 30 tablets were dispensed to him today along with instructions. I have
answered all of his questions to his satisfaction. I will see him back after the current MRIs have
been completed. Time face-to-face was 45 minutes. Time required to review the medical records
was 45 minutes, for a total of 1 hour and 30 minutes.
John P. Estivo, D.O.
JPE/tkb
cc:
EMC
DAVIS, NOLAN
07/27/2016
CURRENT STATUS: The patient is following up with me for the treatment of his cervical and
lumbar spines. He has been attending physical therapy. He believes physical therapy is helping.
He denies any pain or numbness to the upper or lower extremities. He denies any changes in
bowel or bladder control. He states overall he is having less pain to the cervical and lumbar
spines. He has no other complaints.
PHYSICAL EXAMINATION: The cervical spine reveals some mild generalized discomfort
throughout range of motion. There is some tenderness along the left side of the cervical spine.
Negative Spurling's. Deep tendon reflexes are +2/4 with the biceps, triceps and brachioradialis,
+5/5 strength with the biceps, triceps and brachioradialis bilaterally. The full neurovascular
status is intact with both upper extremities. Full range of motion of both shoulders, both elbows
and both wrists today. He has good grip strength to both hands. The thoracic spine is nontender.
The lumbar spine reveals some discomfort throughout range of motion. Negative straight leg
raising bilaterally. Deep tendon reflexes are +2/4 with the patella and Achilles, +5/5 strength
with hip and knee flexors and extensors, +5/5 strength with plantar flexion and dorsiflexion
strength into both ankles today. He is able to toe walk and heel walk. No sensory or motor
deficits are noted to the lower extremities today. He ambulates with a normal, nonantalgic,
smooth gait.
IMPRESSIONS AFTER EXAMINATION:
1.
Cervical spine strain.
2.
Lumbar spine strain.
RECOMMENDATIONS: I recommend he continue working with the physical therapist on his
cervical and lumbar spines for another two weeks. He is allowed to be working at this time with
temporary restrictions of no more than 35 pounds to be lifted. No constant bending or twisting.
He can perform occasional overhead work. He is continued on meloxicam, 7.5 mg, one p.o.
b.i.d. with food. He is given GI warnings about this medication and 60 tablets were dispensed to
him today along with instructions. I have reminded him that he needs to be doing his exercises
every day on his own at home in addition to working with the therapist. I have answered all of
his questions to his satisfaction. I would like to reevaluate him in three weeks. Total time
required was 25 minutes.
John P. Estivo, D.O.
JPE/tkb
cc:
EMC
DAVIS, NOLAN
08/17/2016
CURRENT STATUS: The patient is following up with me after completing some more physical
therapy to his cervical and lumbar spines. He states he feels as though he has made more
progress. He is having less discomfort now to the cervical spine as well as less lumbar spine
pain. He still does have some mild discomfort to both of those areas, but overall he feels as
though he is continuing to improve. He denies any upper or lower extremity symptoms. He has
no other complaints. He has been taking meloxicam, which he states does help quite a bit as
well.
PHYSICAL EXAMINATION: The cervical spine reveals full range of motion. There is some
mild tenderness to palpation along the left side of the cervical spine into the left trapezius.
Negative Spurling's. Deep tendon reflexes are +2/4 with the biceps, triceps and brachioradialis,
+5/5 strength with the biceps, triceps and brachioradialis bilaterally. The full neurovascular
status is intact with both upper extremities. Full range of motion of both shoulders, both elbows
and both wrists without discomfort. The thoracic spine is nontender. The lumbar spine reveals
some mild tenderness to palpation. There is some mild generalized discomfort throughout range
of motion of the lumbar spine. Negative straight leg raising bilaterally. Deep tendon reflexes are
+2/4 with the patella and Achilles, +5/5 strength with hip and knee flexors and extensors, +5/5
strength with plantar flexion and dorsiflexion strength into both ankles today. He can toe walk
and heel walk. He ambulates with a normal, nonantalgic, smooth gait.
IMPRESSIONS AFTER EXAMINATION:
1.
Cervical spine strain.
2.
Lumbar spine strain.
RECOMMENDATIONS: The patient does have a job that requires him to do quite a bit of
heavy lifting. I do think he would benefit from a work conditioning program prior to a full
release. We will have him attend a work conditioning program over the next two weeks. He
tells me that he feels as though he can do more at work. He would prefer to have his restrictions
decreased. He was given temporary restrictions of no more than 50 pounds to be lifted. He can
perform occasional overhead work. He is continued on meloxicam, 7.5 mg, one p.o. b.i.d. with
food. He is given GI warnings about this medication and 60 tablets were dispensed to him today
along with instructions. I will see him back after he finishes a work conditioning program. He
should be at maximum medical improvement at that time. All of his questions were answered to
his satisfaction today. Time face-to-face was 25 minutes.
John P. Estivo, D.O.
JPE/tkb
cc:
EMC
DAVIS, NOLAN
09/12/2016
CURRENT STATUS: The patient is following up with me after completing a work conditioning
program. He states he is feeling much better. He denies experiencing any cervical spine pain.
He states he has some mild discomfort now and then to his lumbar spine. He denies any upper or
lower extremity pain. He has no complaints today.
PHYSICAL EXAMINATION: The cervical spine reveals full range of motion without any
muscle spasm. No guarding. No tenderness throughout range of motion. No tenderness to
palpation. Negative Spurling's. Deep tendon reflexes are +2/4 with the biceps, triceps and
brachioradialis, +5/5 strength with the biceps, triceps and brachioradialis bilaterally. The full
neurovascular status is intact with both upper extremities. Full range of motion of both
shoulders, both elbows and both wrists without discomfort. The thoracic spine is nontender.
The lumbar spine reveals no tenderness to palpation. He can forward flex and touch past his
knees. He extends and side bends his lumbar spine without any hesitation or discomfort today.
Negative straight leg raising bilaterally. Deep tendon reflexes are +2/4 with the patella and
Achilles, +5/5 strength with hip and knee flexors and extensors, +5/5 strength with plantar
flexion and dorsiflexion strength to both ankles today. He is able to toe walk and heel walk. No
sensory or motor deficits are noted to the lower extremities today. Full range of motion of both
hips, both knees and both ankles without any pain to those joints. He ambulates with a normal,
nonantalgic, smooth gait.
IMPRESSIONS AFTER EXAMINATION:
1.
Resolved cervical spine strain.
2.
Resolving lumbar spine strain.
RECOMMENDATIONS: This patient has only mild discomfort to the lumbar spine that comes
and goes. I would expect those remaining symptoms to resolve with time and exercise. It is my
opinion this patient is currently at maximum medical improvement in relation to the injury claim
of 03/23/2016. This patient does not require any further medical treatment in relation to the
claim of 03/23/2016. This patient does not require any permanent restrictions in relation to the
claim of 03/23/2016. This patient does not appear to have experienced any permanent
impairment in relation to the injury claim of 03/23/2016. The mild symptoms he has to his
lumbar spine at this time should resolve with time and exercise. It would be my opinion,
according to the Sixth Edition of the AMA Guides to the Evaluation of Permanent Impairment,
that there would be a 0% impairment for the injury claim of 03/23/2016.
My opinion is stated within a reasonable degree of medical probability and certainty.
John P. Estivo, D.O.
JPE/tkb
cc:
EMC
MARTINEZ, PABLO
06/27/2016
This 63-year-old male presents today for evaluation and treatment in relation to the injury claim
of 02/25/2015. The patient is seen along with a Spanish-speaking interpreter.
CHIEF COMPLAINT: 1. Lumbar spine pain radiating into the right leg. 2. Right shoulder pain.
HISTORY OF CHIEF COMPLAINT: This 63-year-old male works for Nies Construction. He
tells me that on 02/25/2015 he was standing on a wall when the wall then started to shake. He
fell about 8 feet. He describes having a fracture to his left tibia. He tells me he fell backward
onto a frame, striking his right shoulder and his lumbar spine. He tells me he was initially taken
to St. Francis Emergency Room. He was then treated by Dr. Dart with an ORIF to the left tibia.
He tells me that as he was recovering from his left tibia surgery he continued to notice right
shoulder and lumbar spine pain. The discomfort was more noticeable once he discontinued his
postoperative pain medication. He has been released by Dr. Dart. He has now been sent to me
for further evaluation and treatment of his lumbar spine and right shoulder in relation to the
incident that occurred at work on 02/25/2015.
REVIEW OF MEDICAL RECORDS: The patient was seen at Urgent Care on 02/25/2015. He
presented complaining of left knee pain after experiencing a fall at work. The patient was xrayed. He was diagnosed with a left tibial fracture. He was advised to follow up through
occupational medicine.
The patient was seen on 02/27/2015 through occupational medicine. He was complaining of
pain and swelling to his left knee after experiencing a fall at work. After being examined, he was
diagnosed with a comminuted left proximal tibia fracture. It was recommended he be seen by an
orthopedic surgeon.
On 03/05/2015 the patient underwent an ORIF of a left tibial plateau fracture by Dr. Dart.
On 11/09/2015 the patient had the hardware removed from his left proximal tibia by Dr. Dart.
On 01/27/2016 Dr. Dart assigned a 15% impairment to the left lower extremity in relation to the
injury claim of 02/25/2015.
An Independent Medical Evaluation by Dr. Murati is reviewed from 01/20/2016. The patient
presented complaining of lower back pain, left hip pain, left knee pain and right shoulder pain
along with numbness to his left knee. Dr. Murati’s impressions and recommendations are
reviewed today.
The patient was seen for an Independent Medical Evaluation on Dr. Do on 04/06/2016. Dr. Do’s
impressions were right shoulder pain status post ORIF of left tibia and a lumbar spine strain. He
recommended treatment to the lumbar spine and right shoulder in relation to the injury claim of
02/25/2015.
John P. Estivo, D.O.
06/27/2016
MARTINEZ, PABLO
Page 2 of 3
PAST MEDICAL HISTORY: The patient denies any previous lumbar spine or right shoulder
injuries. He denies any heart disease, lung disease, diabetes, hepatitis, ulcers or kidney disease.
PAST SURGERIES: He has had an ORIF of the left tibial plateau fracture, followed by
removal of hardware by Dr. Dart.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: He states he is married. He rarely drinks alcohol. He smokes cigarettes.
He denies any drug use.
REVIEW OF SYSTEMS: Eyes: Negative. Respiratory: Negative. Genitourinary: Negative.
Cardiovascular:
Negative.
Gastrointestinal:
Negative.
Psychiatric:
Negative.
Musculoskeletal: Negative. Neurological: Negative.
PHYSICAL EXAMINATION: Reveals a 63-year-old male. He is 5 feet 2 inches tall. He
weighs 160 pounds. He is right hand dominant. The cervical spine reveals full range of motion
without discomfort. No muscle spasm. No guarding. Negative Spurling's. Deep tendon
reflexes are +2/4 with the biceps, triceps and brachioradialis, +5/5 strength with the biceps,
triceps and brachioradialis bilaterally. The full neurovascular status is intact with both upper
extremities. The right shoulder reveals some tenderness throughout range of motion. There is
some tenderness with overhead movements. Negative drop arm, negative Yergason, negative
apprehension sign, negative Hawkins, negative Speed's and negative O'Brien. No instability.
The right elbow and right wrist have full range of motion without discomfort. The left shoulder,
left elbow and left wrist have full range of motion without any discomfort today. The thoracic
spine is nontender. The lumbar spine reveals some tenderness to palpation. There is tenderness
throughout range of motion of the lumbar spine. Negative straight leg raising bilaterally. Deep
tendon reflexes are +2/4 with the patella and Achilles, +5/5 strength with hip and knee flexors
and extensors, +5/5 strength with plantar flexion and dorsiflexion strength to both ankles today.
He can toe walk and heel walk. He ambulates with a normal, nonantalgic, smooth gait.
X-rays of the right shoulder were ordered, taken and reviewed today, AP, lateral and axillary
views, revealing no fractures, no subluxation, no dislocation and no acute abnormalities seen.
There are some normal age related degenerative changes seen.
X-rays of the lumbar spine were ordered, taken and reviewed today, AP and lateral views as well
as two oblique views of the spine and a spot lateral at L5-S1, including flexion and extension
views, revealing age related degenerative changes throughout the lumbar spine. No fractures, no
subluxation, no dislocation and no acute abnormalities seen. No signs of any instability.
John P. Estivo, D.O.
06/27/2016
MARTINEZ, PABLO
Page 3 of 3
IMPRESSIONS AFTER EXAMINATION:
1.
Right shoulder pain.
2.
Lumbar spine pain.
3.
Status post open reduction with internal fixation of a left tibial plateau fracture by
Dr. Dart.
SUMMARY AND RECOMMENDATIONS: I would relate this patient's right shoulder pain
and lumbar spine pain to the incident of 02/25/2015. The prevailing factor and need for medical
treatment for the right shoulder pain and lumbar spine pain would be the incident that occurred at
work on 02/25/2015. He has done extremely well following his left tibial plateau surgery. He
has no complaints at all regarding his left knee. He has no other complaints today other than
right shoulder pain and lumbar spine pain. I would recommend further evaluation of the right
shoulder pain and lumbar spine pain, consisting of MRIs to both of those areas. I would
recommend temporary restrictions of no more than a maximum of 25 pounds to be lifted. No
constant bending or twisting. He can perform occasional over shoulder height work with the
right arm. I have answered all of his questions to his satisfaction with the assistance of a
Spanish-speaking interpreter. I would like to reevaluate him after these studies have been
completed. Time face-to-face was 45 minutes. Time to review the records and produce this
report was 45 minutes, for a total of 1 hour and 30 minutes.
John P. Estivo, D.O.
JPE/tkb
cc::
EMC
MARTINEZ, PABLO
09/26/2016
CURRENT STATUS: The patient is following up with me after undergoing an injection to his
right shoulder on his last visit. He states the injection has helped a great deal. He states he still
does have some right shoulder pain. He states he still does have some lumbar spine pain. He
states that overall his discomfort to both of those areas has significantly decreased. He denies
any pain radiating to the upper extremities. He denies any pain radiating into the lower
extremities. He has no complaints regarding his left knee. He has no other complaints other
than some mild right shoulder pain and lumbar spine pain today.
PHYSICAL EXAMINATION: The cervical spine reveals full range of motion without
discomfort. No muscle spasm. No guarding. Negative Spurling's. Deep tendon reflexes are
+2/4 with the biceps, triceps and brachioradialis, +5/5 strength with the biceps, triceps and
brachioradialis bilaterally. The full neurovascular status is intact with both upper extremities.
The right shoulder reveals some discomfort with overhead movements. Negative drop arm,
negative Yergason, negative apprehension sign, negative Hawkins, negative Speed's and
negative O'Brien. No instability to the right shoulder. Active range of motion of the right
shoulder was measured using a goniometer. He forward flexes to 180 degrees. Extension is to
50 degrees. Abduction is to 180 degrees. Adduction is to 50 degrees. Internal rotation is to 90
degrees. External rotation is to 90 degrees. The right elbow and right wrist have full range of
motion without any pain. The full neurovascular status of the right arm is intact today. The left
shoulder, left elbow and left wrist have full range of motion without any discomfort. The full
neurovascular status of the left arm is intact as well. The thoracic spine is nontender. The
lumbar spine reveals some mild tenderness to palpation. There is some mild tenderness
throughout range of motion of the lumbar spine. Negative straight leg raising bilaterally. Deep
tendon reflexes are +2/4 with the patella and Achilles, +5/5 strength with hip and knee flexors
and extensors, +5/5 strength with plantar flexion and dorsiflexion strength to both ankles today.
He is able to toe walk and heel walk. No sensory or motor deficits are noted to the lower
extremities today. He ambulates with a normal, nonantalgic, smooth gait. He gets on and off the
examination room table without any hesitation.
IMPRESSIONS AFTER EXAMINATION:
1.
Lumbar spine strain.
2.
Right shoulder rotator cuff tendinitis.
3.
Status post open reduction with internal fixation for a left tibial plateau fracture
by Dr. Dart.
RECOMMENDATIONS: This patient is currently at maximum medical improvement in relation
to the injury claim of 02/25/2015. This patient does not require any further medical treatment in
relation to the claim of 02/25/2015. This patient does not require any permanent restrictions in
relation to the claim of 02/25/2015. I would recommend that he continue to exercise on his own
at home as shown to him by the physical therapist. He tells me he is comfortable doing those
exercises. All of his questions were answered to his satisfaction with the assistance of the
Spanish-speaking interpreter today. He is released from my care.
John P. Estivo, D.O.
09/26/2016
MARTINEZ, PABLO
Page 2 of 3
RECOMMENDATIONS (continued):
According to the Sixth Edition of the AMA Guides to the Evaluation of Permanent Impairment,
the lumbar spine regional grid on page 570 would be referred in determining the lumbar spine
impairment rating. This patient is found to be within class 1, which states documented history of
sprain/strain type injury with continued complaints of axial and/or non-verifiable radicular
complaints and similar findings on multiple occasions. Beginning with default grade C, there
would be a 2% whole person impairment. Applying the grade modifiers results in the following:
GMFH 1 with pain; symptoms with strenuous/vigorous activity. GMPE 0 with negative straight
leg raising and normal reflexes of the lower extremities. GMCS 0 with normal age related
degenerative changes seen on the x-rays and lumbar spine MRI.
Applying the net adjustment formula:
GMFH 1 – CDX 1 = 0
GMPE 0 – CDX 1 = -1
GMCS 0 – CDX 1 = -1
The total for the grade modifiers would be -1.
A -1 would move the patient from default grade C to grade A. This would result in a total of 1%
whole person impairment for the lumbar spine strain in relation to the injury claim of
02/25/2015.
In addressing the right shoulder impairment, the shoulder regional grid on page 402 would be
referenced. This patient would be found to be within class 1. Beginning with default grade C,
there would be a 3% impairment to the right upper extremity. Applying the grade modifiers
results in the following: GMFH 1 with pain/symptoms with strenuous/vigorous activity. GMPE
2 with moderate palpatory findings, consistently documented and supported by observed
abnormalities. GMCS 1 with clinical studies confirming the diagnosis, mild pathology. The net
adjustment formula results in the following:
GMFH 1 – CDX 1 = 0
GMPE 2 – CDX 1 = 1
GMCS 1 – CDX 1 = 0
The total for the grade modifiers would be +1.
A +1 would move the patient from default grade C to grade D. This would result in a total of 4%
impairment to the right upper extremity. Referring to Table 15-11, a 4% impairment to the upper
extremity would convert to a 2% whole person impairment.
Referring to the Combined Values Chart on page 604, a 2% whole person impairment combined
with a 1% whole person impairment results in a total of 3% whole person impairment.
John P. Estivo, D.O.
09/26/2016
MARTINEZ, PABLO
Page 3 of 3
RECOMMENDATIONS (continued):
My opinion is stated within a reasonable degree of medical probability and certainty.
John P. Estivo, D.O.
JPE/tkb
cc:
EMC