Insufficient Medical Documentation To Determine Impairment Severity Case Study

This is a 46-year-old female with a 5/9/2014 date of injury. On the date of injury, the claimant was performing cleaning activities as a custodian, and the claimant developed symptoms of pain in an affected shoulder.

He projects the Plaintiff will require pain management care 3-4 times per year and that the Plaintiff’s pain will progress over time. When asked about the fact that prior to the accident, the Plaintiff was already seeking pain management care, Dr. Gonzales stated that he could not determine whether the prior care was for the same pain that the Plaintiff is currently experiencing. He also stated that during his examination of the Plaintiff, the Plaintiff did not convey that she was experiencing any pain in her neck up until the time of the accident. He admitted if she was experiencing neck pain prior to the accident, he would have no way of quantifying any increase in neck pain she may have felt after the accident. He admitted that if the

Alleged disability: Major depressive disorder, heel spurs/fasciitis, arthritis, obsessive-compulsive disorder, mild intellectual disorder, anxiety, and irritable bowel.

The patient is a 94-year-old female who is brought to the emergency room after a mechanical fall on her left knee. She denies any palpitations, headache, chest pain or loss of consciousness prior to the eventl. She does endorse that she is having some shortness of breath. The patient went to kneel down the steps outside the door of her home and fell and injured her knee. It is to be noted that this patient was discharged the day prior to this presentation from Waterview nursing home at which time she used up all of her Medicare days for skilled nursing. The son relates he was told the patient was able walk when he brought her home she could not walk and that she fell. The patient had been in Waterview for 69 days and that the son insisted on her being discharged from the

This 63-year-old claimant is filing a DIB claim alleging disability since 11/14/2014 due to myasthenia gravis, arthritis in both knees, knee replacement needed, right ankle gives out when walking, blurred vision, double vision, and a the inability to see through the left eye unless head is turned.

Isago for the claimed that he was unaware of the claimant’s medical history. However, he knew that Mr. Codd would walk with a slight limp; ever since he has known of Mr. Codd. He said Mr. Codd would sometimes complain about how his back was hurting him but at no time, did Mr. Codd had never insinuated or reported that Mr. Codd’s complaint of lower back pain was a result of his job as a line cook for the Insured. Mr. Isago further noted that he was not aware of why Mr. Codd as to why Mr. Codd would walk with a slight limp. He never bothered to question Mr. Codd about this observation, because he felt that it was not work-related. In regards to comorbidities, Mr. Isago claimed that he had overheard Mr. Codd once informed him about how he had to take insulin for his diabetes which he had had for some time before being hired with the restaurant. He claimed that Mr. Codd never requested or sought medical treatment on his own for any known reportable work-related injuries while working for the insured. Furthermore, he was not made aware of any nonwork-related injuries or illnesses that Mr. Codd complained about or had informed the insured about any known injuries that were

SC placed call to Pa on 2/3/2016 and completed M T/C. The Pa reported no change in health status, falls, ER visit or hospitalization. The did report that he’s entering into a pain management program due to his diagnoses: DJD, Herniated Disks in neck, Vertebrae Deterioration, Osteoarthritis, Rheumatoid Arthritis, Arthritis of the Spine & knee, Bulging Disc – lower back, Lumbar Degenerative Disc Disease, Carpal Tunnel, and Levoscoliosis, with symptom of shooting and stabbing pain at a rate of 9/10 w/o meds and 7/10 w/ meds, headaches, difficulty bending, limited ROM in legs and arms, unsteady gait, knees, Pa stated that his R leg is longer than L leg, and they are going make him a special shoe to make his legs equal so that he can walker better

From an Internal Medicine perspective, the claimant is not considered disabled from 05/04/2017 through the present. The claimant was noted to have hypothyroidism, centrilobular emphysema, and a history of fungal pneumonia. However, it was noted that he had been doing well, and his condition had been stable without new complaints. The objective findings were insufficient to substantiate a functional impairment secondary to his medical condition that would have precluded him from performing his regular job duties during the referenced time period.

2) We understand that it is likely that the employee has a pre-existing medical diagnosis and a specific medical condition which was not communicated to you before. Therefore, it is questionable if his injury is the consequence of work injury or only the manifestation of his existing condition.

The claimant reported that she usually spent her day watching television, reading and listening to the music. She was able to take care of her personal hygiene and grooming, prepared meals three times a day, and did some house chores. She was also able to manage money, as well as to drive a car; she went out by herself every day and participated in social activities. She did not report any physical or mental difficulties; she did not have problems with concentration, memory, understanding or following directions, completing tasks, or getting along with people.

An Application for Adjudication of Claim has been filed on May 10, 2107, alleging a cumulative trauma injury through June 1, 2015 to the bilateral shoulder, bilateral arm, bilateral elbow, bilateral wrist, bilateral finger, neck, back, headache, and sleep.

The injured worker is a 38-year-old male who was injured in an industrial-related incident on 02/15/2007. On the date of injury, the claimant was loading a truck when he suddenly experienced an acute onset of sharp pain in his lower back.

There is no medical evidence contained in the electronic case folder or the self-insured employers file which would support the establishment of this case. There is no prima facie medical evidence. The claimant suffers from a preexisting condition. The claimant’s fall is idiopathic in nature and was not caused or contributed to in any way by any aspect of her work activities. There is no causal relationship between the claimant’s fall and the injuries sustained and her work activities. The self-insured employer protectively raises Section

The evidence in file shows the claimant has a history of post-polio syndrome. She required bilateral knee tendon release of contractures at age 9. She has atrophic lower extremities and ambulates with crutches or gets around on electric wheel chair.

All available documentation submitted for this claim has been reviewed from the perspective of Internal Medicine. The claimant is a female (DOB 07/08/1978) who is claiming disability from 07/10/2017 to 07/31/2017. The claimant works as a Senior Operations Production Coordinator, with job demands such as continuous sitting. The basic description of work was performed via a computer daily.