Dr. Larry Van Such, DC, BE, EE
2240 Morse Road
Columbus, Ohio 43229
January 27th, 2009
Law Offices of Jones and Jones
Re: Jane Doe
Claim Number: 03-55555
Allowances: 354.0-BILATERAL CARPAL TUNNEL SYNDROME
Employer: E.W.H. SPECTRUM
Date of Birth: 05/05/1955
Social Security #: 555-55-5555
Dear Mr. Jones:
The following is in regards to your client, Jane Doe, who presented to our office on January 27, 2009, for examination in regards to the above-mentioned industrial related incident in reference to percentage of Whole Person Permanent Partial Impairment, utilizing AMA Guides, 5th Edition.
HISTORY AND MECHANISM:
Jane Doe presented with ongoing complaints of bilateral wrist pain. She states that these complaints have been present since being involved in an industrial related accident that occurred on the above-mentioned date. She described the mechanism of the injury as repetitive work that occurred while working for the above-mentioned employer. She described her job description, as she was required to work with electrical wires, stripping insulation off them and using a foot pedal on a repetitive basis. She also had to apply pressure to terminals and wires, putting them into a harness on a regular basis. She did rotate to other types of jobs and utilize machinery on a repetitive type of basis. The first doctor she saw after the accident was Dr. Herzog, where she received anti-inflammatory medication. The next doctor she saw was Dr. Stover, Orthopedic Surgeon, where she received diagnostic testing consisting of EMG/NCV of her upper extremities, which confirmed bilateral carpal tunnel syndrome. She had carpal tunnel releases performed by Dr. Stover in 2003. Mrs. Doe then went to see Dr. Hoy, who she is currently under the care of and receives medication from. Mrs. Doe also went to see Dr. Broske, where she received chiropractic treatment.
CURRENT COMPLAINTS AND STATUS:
Jane Doe explained that she no longer works for the above-mentioned employer. The patient states that she missed work due to the surgery. Jane states that the pain comes and goes throughout the day. She describes that pain at a tingling, throbbing, cramping, numbness, stiffness, aching, and spasm sensation. The patient states that she has limited mobility of both her wrists. She states that this injury interferes with her work and sleep. With limited use of her wrists, it is difficult or impossible for her to perform the following activities: doing laundry, doing dishes, running sweeper, cutting lawn, shoveling snow, driving a car, sitting too long, sleeping, standing, and holding small objects. Jane explains that since the injury she has little strength in her wrists and she constantly feels pressure in her wrists.
All of the above mentioned complications fall under the chronic pain category where up to 3% impairment is given/added to this claim based on the ongoing burden of illness disrupting activities of daily living. Janel is given 2% WPI today. Reference AMA guides, 5th edition, Chapter 18, Tables 18-1, 18-3, 18-4, 18-5, 18-6 and page 584 item 5b.
Deep tendon reflexes were +2 and symmetrical of the biceps, triceps, and were elicited bilaterally and equally of the brachial radialis. Phalens test was positive bilaterally. Altered sensations to hot and cold during sensory testing. Pain and tenderness were elicited over the median nerve distribution of the left and right hands. Weakness in thumb abduction is noted in both hands. Grip strength was 20 lbs in the right hand and 20 lbs. in the left hand. She is right hand dominant. The grip strength values are rated a 4 out of 5. Surgical scars were noted in both hands from carpal tunnel release surgery. Right scar measured 2 ˝ cm and left measured 3 cm.
Left Upper Extremity Impairment:
Range of Motion
LEFT WRIST RANGE OF MOTION IMPRESSION:
A.) Flexion = 5% impairment.
B.) Extension = 5% impairment.
C.) Radial Deviation = 2% impairment.
D.) Ulnar Deviation = 2% impairment.
Total left wrist impairment = 14% UEI according to AMA Guides, 5th Edition, Chapter 16, pages 467-470.
Sensory testing: The patient was unable to discern between two sharp points of contact within 40mm (<5mm is normal) over the radial 3 ˝ digits in the left wrist (C6 and C7 dermatomes). This equates 5% UEI, Table 16-13, page 489.
Total Left UEI calculation
uusing combined values chart page 604
14% combined with 5% = 18%
Total Left WPI calculation
An 18% UEI equals an 11% WPI. Table 16-3, page 439
Right Upper Extremity Impairment:
Range of Motion
RIGHT WRIST RANGE OF MOTION IMPRESSION:
A.) Flexion = 0% impairment.
E.) Extension = 5% impairment.
F.) Radial Deviation = 2% impairment.
G.) Ulnar Deviation = 2% impairment.
Total right wrist impairment = 9% UEI according to AMA Guides, 5th Edition, Chapter 16, pages 467-470.
Sensory testing: The patient was unable to discern between two sharp points of contact within 40mm (<5mm is normal) over the radial 3 ˝ digits in the right wrist (C6 and C7 dermatomes). This equates 5% UEI, Table 16-13, page 489.
Muscle strength deficits were noted during right wrist flexion and extension grading out to be 4/5 in muscle strength. Reference 16.8a, page 508, for rules regarding combining more than one type of impairment.
Motion: right wrist flexion
Muscle(s): Flexor carpi radialis/ulnaris
Nerve: Median and ulnar nerves
Value of Nerve: 35% (Table 16-15, page 492)
Muscle grade: Max: 5 lbs force; Grade 4 = 1-25% (Table 16-11, page 484)
Calculation: 35% x 25% = 8.75% = 9% UEI
Total Right UEI calculation
Using combined values chart page 604
9% combined with 9% = 17%
17% combined with 5% = 21%
Total Right WPI calculation
A 21% UEI equals a 13% WPI. Table 16-3, page 439
Total Left and Right WPI calculation
Using combined values chart page 604
13% (right) combined with 11% (left) = 23% WPI
23% + 2% (pain/ADL’s) = 25% WPI
DISCUSSION AND OPINION:
The following impairment rating has been given to Jane Doe after a thorough history, orthopedics, neurological, muscle testing, and range of motion examinations were performed on January 27, 2009. It is my professional opinion that Mrs. Doe has sustained a 25% Whole Person Impairment.
This impairment rating falls into the Range of Motion category, November 2000, 5th Edition AMA Guides to the Evaluation of Permanent Impairment.
Dr. Larry Van Such, D.C., B.E.
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