Case IV:
PEDESTRIAN vs. MOTOR
VEHICLE ACCIDENT WITH FRACTURE,
SPINAL STRAIN
ASSESSMENT:
Chronic cervical musculoskeletal ligamentous strain, motor vehicle
accident 8/21/95.
Chronic lumbosacral musculoskeletal ligamentous strain, motor vehicle
accident 8/21/95.
Status post bimalleolar right ankle fracture with dislocation and right
fibula fracture, open reduction/internal fixation with post surgical
scarification and residual limited range of motion of right foot, motor vehicle
accident 8/21/95.
Status post posterior anterior cruciate ligament repair and lateral
meniscectomy of right knee with residual dysesthesia right lower extremity and
post surgical scarification, motor vehicle accident 8/21/95.
Post traumatic scarification scalp, upper back, arms and hands and
hypo/hyper pigmentation left forearm secondary to thermal injury, motor vehicle
accident 8/21/95.
History of post traumatic headaches with memory dysfunction secondary to
post traumatic closed head brain injury, motor vehicle accident 8/21/95.
Post traumatic post surgical dysesthesia of the upper extremities, rule
out peripheral neuropathy, cubital tunnel syndrome, carpal tunnel syndrome,
motor vehicle accident 8/21/95.
Post traumatic post surgical dysesthesia of the right lower extremity,
motor vehicle accident 8/21/95.
History of post traumatic chest wall pain, motor vehicle accident
8/21/95.
Status post fracture left jaw surgically repaired with residual post
traumatic post surgical dysesthesia of the left cheek and low grade deformity,
motor vehicle accident 8/21/95.
History of post traumatic depression and anxiety, motor vehicle accident
8/21/95.
History of asthma.
Allergy to penicillin and cats.
PERMANENT
FUNCTIONAL IMPAIRMENT RATING BASED ON THE AMA GUIDES TO THE EVALUATION OF
PERMANENT IMPAIRMENT, 5th EDITION:
When
combined and rounded to the nearest value ending with 0 or 5 this examinee has a
permanent injury resulting in a permanent functional impairment rating of 25% to
the body as a whole secondary to injuries from the above mentioned motor vehicle
versus pedestrian accident of 8/21/95.
In my opinion, by review of available pertinent medical records, history, physical examination and diagnostic studies, this examinee’s present condition is the result of the pedestrian versus motor vehicle accident of 8/21/95.
Prior to 8/21/95, the examinee had no history of preexisting condition, physical restrictions or limitations. Subsequent to the pedestrian versus motor vehicle accident of 8/21/95, the examinee sustained two additional motor vehicle accidents on 12/18/96 and 6/18/98, which exacerbated his preexisting condition though did not contribute to additional permanent injury.
The pedestrian
versus motor vehicle accident of 8/21/95 caused the diagnoses noted in the
aforementioned assessment.
The examinee has been advised of the permanent nature of his injury and of having achieved maximum medical improvement.
The examinee is encouraged to continue with his normally regular routine exercise program of weight lifting stretching, strengthening and overall conditioning though is cautioned to avoid and any and all overly strenuous activities which may aggravate his underlying condition. Should the examinee develop an acute exacerbation he is instructed to seek modalities of physical therapy, hydrotherapy, neuromuscular massage, use a TENS unit, and take anti-inflammatories and/or muscle relaxants as needed to diminish pain, extend flexibility and improve function. The examinee may benefit from using a cervical pillow and lumbosacral support cushion and, when doing any potentially overly strenuous or repetitive bending, twisting or lifting, a lumbar support belt. The examinee should use supportive shoes, avoid uneven surfaces, and any and all other activities which may lead to increased twisting or straining of the right lower extremity.
With regard to the examinee’s history of mild short term memory loss, the examinee is encouraged to continue with his regular work as an area manager though periodically may have a need for additional psychological support.
Anticipated annual expenses
for the aforementioned recommendations would
be approximately $1,500-$3,000 annually to include medications, therapy,
physical rehabilitation, medical evaluation and supplies.
MEDICAL OPINIONS:
The
examinee has been advised of the opinion of Dr. M.D., physical medicine,
neurologic and orthopaedic rehabilitation and electrodiagnosis, (1/26/98), that
he has not and will not reach his pre-injury level and that he has sustained
significant permanent injuries as a result of the pedestrian versus motor
vehicle accident of 8/21/95 and will require ongoing physical therapy,
psychological support and perhaps additional surgery and that the examinee’s
ability to compete in the workplace shall be compromised.
The
examinee has been advised of the opinion of Dr. M.D., neurologist (1/29/98),
after comprehensive neuropsychological evaluation that the examinee has brain
damage which is accident related for which he (Dr. M.D., neurologist) has
nothing more to offer, and the examinee is at maximum medical improvement.
PHYSICAL
LIMITATIONS
The examinee should avoid twisting, turning on the
right leg, prolonged standing or overly
Should the examinee's symptoms worsen he should seek
medical reevaluation.
The
review of additional pertinent medical records and/or diagnostic studies may
have the effect of modifying the examinee’s permanent functional impairment
rating.
THE
HEALTH PLACE
A Private Medical Practice of David P. Kalin, M.D., M.P.H.
P.O. Box 6009
Palm Harbor, Fl 34684
Tel 813.966.1431 Fax
813.925.1932
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