Docstoc

Gilbert Varela, MD, Inc

Document Sample
Gilbert Varela, MD, Inc Powered By Docstoc
					                             Gilbert Varela, M.D., Inc.
                             5230 E. Beverly Boulevard
                            Los Angeles, California 90022
                               Phone: (323) 724-6911
                                Fax: (323) 724-6915


August 20, 2007



THE LAW OFFICES OF
Los Angeles, California 90063



                     REGARDING:
      SOCIAL SECURITY NUMBER:
                      EMPLOYER:
                    OCCUPATION:
                  DATE OF BIRTH:
                 DATE OF INJURY:
    DATE OF INITIAL EXAMINATION:
                  CLAIM NUMBER:
                  WCAB NUMBER:


         SAMPLE INITIAL WORKERS COMPENSATION MEDICAL REPORT


INTRODUCTION:

Mr. xxxxxxxxx is a 28-year-old, right-handed male who was evaluated in this office on
August 20, 2007 for injuries incurred in a work-related accident in March 2007.

HISTORY OF PRESENT ILLNESS:

According to the patient, he was unloading a box containing heavy weights and, as the
box started to fall, he attempted to steady it. At that time, he felt a crack and a pulling
sensation stemming in his neck and radiating into his upper back. He reported the
injury to his manager, Agustin, approximately three days after the accident. He was
then placed on light duty including sweeping the area. The patient stated that he was
never referred for medical treatment by his company. He further stated that he was
accused of theft by the security guard in March 2007 at which time he retained the
services of an attorney and was referred to this office for evaluation and treatment.
CHIEF COMPLAINTS:

The patient’s chief complaints at the time of initial evaluation included pain in his neck
and upper back rated at 5/10 on the pain scale.

In regard to his neck, he described the pain as a localized, pulling and stretching type of
pain accompanied by weakness that was aggravated by bending, squatting, pushing,
pulling, kneeling, ascending stairs, reaching, and carrying or lifting objects weighing
greater than ten pounds. He stated that the pain was somewhat alleviated by the use of
analgesic medication.

In regard to his upper back, he described the pain as a localized, pulling and stretching
type of pain accompanied by weakness that was aggravated by bending, squatting,
pushing, pulling, kneeling, ascending stairs, reaching, and carrying or lifting objects
weighing greater than ten pounds. He stated that the pain was somewhat alleviated by
the use of analgesic medication.

IMPAIRMENT OF ACTIVITIES OF DAILY LIVING:

The patient reported impairment in the following activities of daily living due to his
industrial-related injuries:

   1. Reclining due to an exacerbation of pain in his neck.
   2. Resting and sleeping through the night due to increased pain in his neck and
      upper back.
   3. Lifting objects weighing greater than ten pounds due to increased pain in his
      neck and upper back.
   4. Traveling due to due to increased pain in his neck and upper back with prolonged
      sitting.

JOB DESCRIPTION:

The patient is an employee of EESI Payroll and Staffing Services.           He has been
employed at the company since October 2006 as a laborer.

The patient works approximately eight hours per day, five days per week. In a usual
workday, he spends the entire shift performing standing, walking, pushing and pulling
types of activities. He is frequently required to stoop, crouch, bend, climb, squat, and
reach. He uses both hands in a repetitive motion for pushing, pulling, holding, grasping,
and fine manipulation. He works around moving machinery and is required to drive
heavy equipment. He is exposed to marked changes in temperature and humidity as
well as dust, fumes, and gasses in his work environment.
Following the accident, the patient he continued working. He reported the accident.
The patient was not referred for medical treatment by his employer.

REVIEW OF PAST MEDICAL RECORDS:

There are no previous pertinent medical records in regard to this accident.

PAST MEDICAL HISTORY:

PRIOR INJURIES:            The patient denied any previous injuries either industrial or
                           non-industrial.

SURGERIES:                 The patient reported having undergone surgery for the repair
                           of an inguinal hernia in the past.

ILLNESSES:                 The patient denied any history of serious illness such as
                           hypertension, diabetes, cardiac disease, or arthritis.

DRUG ALLERGIES:            The patient denied any known drug allergies.

SOCIAL HISTORY:            The patient is married and has no children. He reported the
                           consumption of alcoholic beverages on an average of three
                           times per week and the smoking of approximately four
                           cigarettes per day.

FAMILY HISTORY:            The patient’s family history is essentially non-contributory.

PHYSICAL EXAMINATION:

GENERAL:                   The patient is a 28-year-old, right-handed male who is well
                           nourished, alert, responsive, and cooperative.

VITAL SIGNS:               Stable.

SKIN:                      The skin was clear with no bruises, abrasions, or lacerations
                           noted.

HEAD:                      The head was normocephalic with no external signs of
                           injury.

EENT:                      The pupils were equal, round, and reactive to light and
                           accommodation. The tympanic membranes were intact.
                           The nose and throat were clear.
CHEST:                   The chest was symmetrical. Normal AP diameter and
                         respiratory excursions were noted. Examination of the rib
                         cage was within normal limits.

LUNGS:                   The lungs were clear to percussion and auscultation.

HEART:                   The heart had regular rate and rhythm without murmurs or
                         gallops.

ABDOMEN:                 Examination of the abdomen revealed the presence of
                         tenderness on palpation of the umbilical region. No masses
                         or lesions were noted on palpation.

CERVICAL SPINE:          Inspection of the cervical spine revealed normal lordosis
                         without evidence of antalgic positioning. Examination of the
                         cervical spine revealed tenderness on palpation of the
                         spinous processes and paraspinal musculature. No spasms
                         were detected on palpation. No guarding was noted on
                         examination.     Foraminal Compression was negative.
                         Distraction was negative. No motor or sensory deficit to
                         either upper extremity was noted. Range of motion was as
                         follows:

                         Measurement            Normal           Pain

Flexion:                 45 degrees             45 degrees       No
Extension:               45 degrees             45 degrees       No
Right lateral bending:   45 degrees             45 degrees       No
Left lateral bending:    45 degrees             45 degrees       No
Right rotation:          60 degrees             60 degrees       No
Left rotation:           60 degrees             60 degrees       No

THORACIC SPINE:          Inspection of the thoracic spine revealed normal kyphosis
                         without evidence of scoliosis. Examination of the thoracic
                         spine revealed tenderness on palpation of the spinous
                         processes and paraspinal musculature. No spasms were
                         detected on palpation.      No guarding was noted on
                         examination.

LUMBOSACRAL SPINE: Inspection of the lumbosacral spine revealed normal lordosis
                   without evidence of scoliotic curvature. Examination of the
                   lumbar spine was negative for tenderness and spasm on
                   palpation of the paraspinal musculature and spinous
                   processes.     The straight leg raise test was negative
                   bilaterally No motor or sensory deficit to either lower
                   extremity was noted. Range of motion was as follows:
                          Measurement                 Normal               Pain

Flexion:                      80 degrees              75-90 degrees        No
Extension:                    30 degrees              30 degrees           No
Right lateral bending:        35 degrees              35 degrees           No
Left lateral bending:         35 degrees              35 degrees           No
Right rotation:               45 degrees              45 degrees           No
Left rotation:                45 degrees              45 degrees           No

SHOULDERS:                    Examination of the shoulders revealed them to be
                              symmetrical and without elevation bilaterally. No tenderness
                              was present on palpation of the shoulder musculature
                              bilaterally. No motor or sensory deficit to either shoulder
                              was noted. Range of motion was as follows:

                              Right                   Left                 Normal

Flexion:                      180 degrees             180 degrees          180 degrees
Extension:                     60 degrees              60 degrees           60 degrees
Abduction:                    180 degrees             180 degrees          180 degrees
Adduction:                     50 degrees              50 degrees           50 degrees
External rotation:             90 degrees              90 degrees           90 degrees
Internal rotation:             90 degrees              90 degrees           90 degrees

ARMS/FOREARMS:                Examination of the arms and forearms was within normal
                              limits bilaterally.

ELBOW/WRIST/HAND:             Examination of the elbows, wrists, and hands was within
                              normal limits bilaterally.

KNEES:                        Examination of the knees was within normal limits bilaterally.

HIPS/THIGHS:                  Examination of the hips and thighs was within normal limits
                              bilaterally.

LEG/ANKLE/FOOT:               Examination of the legs, ankles, and feet was within normal
                              limits bilaterally.

NEUROLOGICAL:

   Mental Status:             Alert and oriented times three
   Speech:                    Normal
   Cranial Nerves II – XII:   Grossly intact
   Gait:                      Non-antalgic
   Coordination:              Finger-to-nose and finger-to-finger normal
   Reflexes:                  Bilaterally equal and reactive
   Motor Sensory:             No deficit noted
DIAGNOSES:

1. CERVICAL SPINE SPRAIN AND STRAIN.
2. THORACIC SPINE SPRAIN AND STRAIN.

TREATMENT PLAN:

After a complete physical examination, the patient was prescribed a course of physical
therapy to be scheduled three times per week for a period of four weeks.

PRESCRIPTIONS:

1. No prescriptions were issued at this time.

REFERRALS:

1. The patient was referred to undergo MRI scans of the cervical spine and thoracic
   spine.

FOLLOW-UP:

The patient is to return to my office for reevaluation of the work-related injuries in four
weeks.

DISABILITY STATUS:

The patient’s condition is considered temporarily and totally disabled from August 20,
2007 through September 20, 2007.

CAUSATION:

Having had the opportunity to evaluate this patient, it is my opinion that the patient’s
symptoms are related to his work injury.

WORK RESTRICTION:

In regard to the patient’s lumbar spine, and cervical spine, he is restricted to no heavy
work.


PROGNOSIS:

The patient’s prognosis is guarded


.
REQUEST FOR AUTHORIZATION:

I am officially requesting authorization for the above-noted treatment and I have
provided an objective basis for the reasoning behind my treatment recommendations.
The proposed treatment is consistent with the American Society of Interventional Pain
Physicians (ASIPP) and Evidence-Based Practice Guidelines listed in the National
Guidelines Clearinghouse that quotes 1175 references. SB 899, SB 227, and AB 227
(which resulted in Labor Code 4604.5) clearly stated that peer-reviewed scientific
research can be used to supersede and replace what is in or omitted from the ACOEM
Guidelines that are to be applied to the utilization review process not necessarily the
ACOEM guidelines. ACOEM stresses that the guidelines are not hard and fast rules.
The ACOEM guideline applies to acute (less than three months old) injuries and is not
appropriate in this patient's case.

Authorization of any treatment and diagnostic studies that were previously mentioned in
this report is requested based upon medically reasonable treatment requirements. This
is according to Labor Code 4600 and Title 8 Section 9792.6 C.C.R. and Rule 9784.
Therefore, we are requesting written authorization to be sent to us within seven (7)
working days as required by 8 C.C.R. 9792.6. Any denial of request for authorization
must include a written explanation of the basis of denial. We will schedule this patient
for the above-listed recommended tests once authorization becomes available.

DISCLOSURE/AFFIDAVIT OF COMPLIANCE:

This report is for medical/legal assessment and is not to be construed as a complete
physical examination for general health purposes. Only those symptoms which I
believed to have been involved in the injury, or might relate to the injury, have been
assessed.

According to labor code 4628, I declare under penalty of perjury that the information
contained in this report and its attachments, if any, is true and correct to the best of my
knowledge and belief, except as to information that I have indicated I have received
from others. As to that information, I declare under penalty of perjury that the
information accurately describes the information provided to me and, except as noted
herein, that I believe is to be true.

I have not violated Labor Code Section 139.3, and the contents of the report and bill are
true and correct to the best of my knowledge. This statement is made under penalty of
perjury.

Dated this _____day of ________________ 2007 at Los Angeles County, California.

Sincerely,



Gilbert R. Varela, M.D.
GRV:sfb

				
DOCUMENT INFO
Shared By:
Stats:
views:6
posted:6/25/2011
language:Spanish
pages:7