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Dr. Larry Van Such, DC, BE, EE
(614) 428-9310 Law Offices of Jones and Jones J. R. Jones Attorney at Law Telephone: (614) 555-5555 Facsimile: (614) 555-5556 Re: Robert Bigler Claim Number: 94-486061 D.O.I.: Allowances: 847.2- LOW BACK STRAIN 847.1-MID BACK STRAIN 840.8-RIGHT TRAPEZIUS STRAIN 840.9 Shoulder Sprain Strain Date of Birth: Social Security #: 292-58-9263 Dear Mr. Jones: The following is in regards to your client, John Doe, who presented to our office on HISTORY AND MECHANISM: John Doe presented with ongoing complaints of low back pain, mid back, and right trapezius pain. He states that these complaints have been present since being involved in an industrial related accident that occurred on the above-mentioned date. He described the mechanism of the injury as when he was moving a 12ft. ladder back to the stock room when he twisted his back. The first facility he went to after the accident was Ohio State Medical Care, where they took x-rays and prescribed pain medication. The next doctor Mr. Doe saw was Dr. Andy Granger, where he received x-rays, physical therapy, massage, and pain medication. CURRENT COMPLAINTS AND STATUS: John Doe explained that he no longer works for the above-mentioned employer. The patient states that he missed one week of work. Mr. Doe states that the pain is constant. He describes the pain as a burning, dull, stiffness, aching, and shooting sensation. The patient states that he has limited mobility of his low back, mid back, and right trapezius. He states that this injury interferes with his work, sleep, daily routine, and recreation. With limited use of his low back, mid back, and right trapezius, it is difficult or impossible for him to perform the following activities: climbing stairs, doing laundry, doing dishes, running sweeper, shoveling snow, raking leaves, gardening, driving a car, sitting too long, standing, walking, lifting weights, exercising, running, jogging, sleeping, standing, shopping with spouse, grocery shopping, and lifting anything. 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. John is given 1% 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. OBJECTIVE: Musculoskeletal Deep tendon reflexes were +2 and symmetrical of the biceps, triceps, and were elicited bilaterally and equally of the brachial radialis. Apley’s test was positive on the right. Hypertonicity was palpated in the rhomboids and trapezius muscles on the right. Muscle tenderness was palpated over the lumbar erector spinae. Nachlas test was positive. Motion palpation revealed fixations at L4/L5 and L5/S1 during extension of the lumbar spine. Postural analysis revealed an elevated shoulder on the right, head tilt to the right, and an elevated ilium on the right. Dorsolumbar ranges of motion (digital inclinometer)
DORSOLUMBAR IMPRESSION: A.) Flexion = 4% impairment. B.) Extension = 2% impairment. C.) Left Lateral Flexion = 1% impairment. D.) Right Lateral Flexion = 2% impairment. Total whole person impairment = 9% WPI, based on AMA Guides, 5th Edition, Chapter 15, Table 15-8, page 407 and Table 15-9, page 409. Thoracic range of motion
THORACIC A) Flexion = 2% impairment B) Left Rotation = 2% impairment. C) Right Rotation = 1% impairment. Total whole person impairment = 5% WPI, based on AMA Guides, 5th Edition, Table 15-10, page 411 and Table 15-11, page 414.
RIGHT SHOULDER IMPRESSION: A.) Flexion = 5% impairment. B.) Extension = 0% impairment. C.) Right Abduction = 5% impairment. D.) Right Adduction = 1% impairment. E.) Right Internal Rotation = 2% impairment. F.) Right External Rotation = 0% impairment. Right upper extremity impairment = 13% UEI, based on AMA Guides, 5th Edition, Chapter 16, pages 474-479. Reference AMA Guides, 5th Edition, Chapter 16, page 439, table 16-3. Relationship of the impairment of the upper extremity to the whole person impairment: A 13% upper extremity impairment = 8% WPI. Total WPI Calculation (combined values chart page 604) 9%WPI combined with 8% WPI = 16% WPI 16% WPI combined with 5% = 20% WPI 20% plus 1% (Pain/ADL’s) = 21% WPI DISCUSSION AND OPINION: The following impairment rating has been given to John Doe after a thorough history, orthopedics, neurological, muscle testing, and range of motion examinations were performed on This impairment rating falls into the Respectfully Submitted, Dr. Larry Van Such, D.C., B.E.
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