Download Case Presentation - Seymour Levine

SEYMOUR LEVINE, M.D.
A PROFESSIONAL CORPORATION
DIPLOMATE, AMERICAN BOARD OF INTERNAL MEDICINE
DIPLOMATE, AMERICAN BOARD OF RHEUMATOLOGY
1125 SO UT H BEVERLY DRIVE, SUITE 425
LOS ANGELES, CALIFO RNIA 90035
T ELEPHO NE: (310) 657 -2855 - F AX: (310) 657 -7433
May 30, 2016
AGREED MEDICAL EVALUATION IN RHEUMATOLOGY
To Whom It May Concern:
This case involves an Agreed Medical Evaluation in Rheumatology that I performed on a
71-year-old woman. From the rheumatologic perspective, I was asked to assess this
patient regarding any evidence for the presence of a connective tissue disease that
preceded the date of injury in this case. The injury occurred in the year 2007. From the
rheumatologic perspective, the issues in this case revolved around whether this patient
had any rheumatologic diagnoses or rheumatologic injury, and whether she sustained
disability on a rheumatologic basis. I was asked to determine whether any such
rheumatologic disability was generated on an industrial basis. Along with this I was
asked to address the usual issues in a Workers’ Compensation case.
HISTORY OF THE PRESENT ILLNESS:
This patient sustained industrial injuries on an orthopedic basis resulting in strains of the
cervical and lumbar spines, the bilateral shoulders, the bilateral knees, and the bilateral
elbows. I deferred on these injuries to the AME in Orthopedics.
This patient had been evaluated by a rheumatologist some two years before her industrial
injury. At that time she presented with Raynaud’s phenomenon and was felt to have
Undifferentiated Connective Tissue Disease characterized by arthralgias, myalgias,
Raynaud’s phenomenon, sclerodactyly, and dry eyes. The rheumatologist documented
significant myofascial pain in this patient preceding her industrial injury with the
myofascial pain involving the musculature of the cervical and lumbar spines and the
musculature of the bilateral shoulder girdles. At that time a diagnosis of fibromyalgia
was suspected, but never definitively established in this patient prior to the industrial
injury. There were no work restrictions despite the underlying preexisting connective
tissue disease in this patient. She was fully capable of doing her usual work at a local
department store.
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May 30, 2016
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Once the patient developed pain secondary to the industrial injury, she left work never
returning to work. Her clinical course was complicated by the development of
widespread pain associated with a number of nonspecific somatic complaints including
nonrestorative sleep, chronic fatigue, symptoms consistent with depression and anxiety,
symptoms consistent with cognitive dysfunction, headaches, intermittent vertiginous
complaints, and symptoms consistent with an irritable bowel syndrome. The patient was
seen by a consulting rheumatologist who diagnosed her as having fibromyalgia. The
patient’s treating rheumatologist accepted the diagnosis of fibromyalgia, but also felt that
the patient had a limited form of scleroderma.
QUESTIONS FROM THE AUDIENCE REGARDING THIS PATIENT’S
HISTORY AND CLINICAL PRESENTATION:
On physical examination, this patient demonstrated changes consistent with Raynaud’s
phenomenon. She had purplish and cool toes and purplish distal phalanges of her fingers
in the air conditioned examination room. There was a slight degree of sclerodactyly
involving the distal fingers referred to as tightening of the skin. The musculoskeletal
exam revealed mild tenderness on palpation of the masseter muscles and the paracervical
muscles. There was moderate tenderness on palpation of the paralumbar muscles. There
was very mild tenderness on palpation of the parathoracic and rhomboid muscles. There
was adequate range of motion of the cervical and lumbar spines. There was very mild
tenderness on palpation of the subacromial bursae. There was very mild tenderness on
palpation of the lateral and medial epicondyles of the elbows. There was mild tenderness
on palpation of the joint lines of both knees. There was no overt synovitis involving the
peripheral joints. On examination for fibromyalgia, the patient demonstrated all 18 of the
classical 18 tender points.
In assessing this patient for the diagnosis of fibromyalgia, she met both the original
classification criteria for the diagnosis of fibromyalgia as established by the American
College of Rheumatology in 1990, and also met the new 2010 diagnostic criteria for
fibromyalgia also established by the American College of Rheumatology. She had an
Epworth Sleepiness Scale score of 19 representing excessive daytime sleepiness.
Significant fatigue was noted on a Fatigue Severity Scale. Utilizing Table 18-4 on page
586 of the AMA Guides which is entitled “Ratings Determining Impairment Associated
with Pain”, this patient had a total pain related impairment score of 56, putting her into
the moderately severe impairment class regarding her chronic pain.
In reference to laboratory testing, this patient had a weakly positive antinuclear antibody
and low levels of antibodies to phosphatidylserine, a phospholipid. There were no other
autoantibodies detected, nor were there any other significant laboratory findings.
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May 30, 2016
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This patient was followed by a number of medical care providers. In addition to her
primary care physician, she sees a rheumatologist on a regular basis. She also sees an
oncologist due to a history of breast cancer that preceded the industrial injury by one
year. At that time, she was treated with a lumpectomy and radiation therapy. She also
has access to a pain management specialist on an as needed basis, as well as to a
neurologist.
In terms of the pharmacologic approach in treating this patient’s conditions, she is on
Cymbalta 60 mg daily for fibromyalgia. From the internal medicine perspective, she was
found to have gastroesophageal reflux disease (GERD) for which she is on a proton pump
inhibitor and H2 blocker. Her esophageal disease has been felt to be part and parcel of
her underlying Undifferentiated Connective Tissue Disease for which she is maintained
on medications to treat the GERD. Aerobic exercise was recommended and the patient
uses a stationary bike. The patient is receiving Social Security, but also receives
payments through the Workers’ Compensation System twice a month. She is clinically
stable in terms of her Undifferentiated Connective Tissue Disease and fibromyalgia
syndrome. She was considered to be permanent and stationary for rating purposes and to
have achieved maximal medical improvement from the rheumatologic perspective some
four years after her injury which was in October 2011.
ISSUES FOR DISCUSSION:
As noted above, I was asked by the parties to define whether this patient has a
rheumatologic disorder, any disability from such a rheumatologic disorder, and whether
such disability is related to industrial exposures. I was asked to address the usual issues
in a Workers’ Compensation case including whether this patient is permanent and
stationary for rating purposes and has achieved maximal medical improvement. The
usual issues would include a discussion of the subjective and objective factors of
disability, work restrictions, whole person impairment utilizing the AMA Guides, fifth
edition, causation and apportionment, and future treatment.
QUESTIONS FOR THE AUDIENCE:
1.
What would be the appropriate way to assess this patient’s underlying nonindustrial rheumatologic disorder which has been defined as Undifferentiated
Connective Tissue Disease? How is it determined whether there has been
exacerbation or aggravation of such an underlying non-industrial condition? Is
there any permanent disability or whole person impairment from autoimmune
diseases in general?
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May 30, 2016
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2.
In reference to fibromyalgia, does this patient actually have fibromyalgia? Did the
patient have fibromyalgia prior to the industrial injury? What is the relationship
between fibromyalgia and this patient’s underlying non-industrial connective
tissue disease? Since fibromyalgia is not rated in the AMA Guides, how does one
assess permanent disability and whole person impairment regarding fibromyalgia?
Is fibromyalgia apportionable in this patient’s case?
3.
What appropriate treatment would be indicated from the rheumatologic
perspective in terms of this patient’s future care? This could include appropriate
providers, medications, and therapeutic modalities.
4.
What consults would be appropriate to use in this patient’s case? This patient was
evaluated by an AME in Orthopedics and an AME in Internal Medicine.
ADDITIONAL COMMENTS AND QUESTIONS:
Yours truly,
SEYMOUR LEVINE, M.D.
SL/sgs: (1917)