Case VIII:
DIAGNOSES:
Cyclothymia.
History of anorexia nervosa.
History of polysubstance dependence in controlled environment (marijuana,
cocaine inhalation, alcohol).
History of personality disorder with antisocial obsessive borderline
traits.
Status post lumbar diskectomy and fusion, 2/17/99.
Large herniated left disc
protrusion, probably herniated nucleus pulposus L5-S1; two small disc
protrusions from L2-3 to L4-5 (MRI 9/3/98).
Mild degenerative disease
L3-4, L4-5 with mild disc space narrowing and sclerosis without evidence of
acute fracture or spondylolisthesis with moderate rotary scoliosis, slightly
more severe on 6/15/98 (x-rays 1993, 9/24/97, 6/15/98).
History of chronic lower back
pain syndrome with left L5-S1 radiculopathy since 1993.
History of bipolar disorder with modulation from depression to mixed
hypomania, treated with Zoloft, Depakote, Mellaril, Ativan and Vistaril.
Status post surgery for
deviated septum.
History
of hay fever.
History of penicillin and codeine allergy.
Pyuria (urinalysis 9/17/97).
Upper respiratory infection, 10/30/97.
Contusions back, left leg and possible right lower back strain, 5/18/98.
Scrape of the bottom of the left foot, 5/27/98.
Back pain, 5/29/98.
Possible urinary tract infection, 6/7/98.
Lumbar spondylosis or sciatica, rule out intervertebral disc, 6/19/98.
Possible dizziness, rule out eating disorder, 7/5/98.
Possible seizure/fall, 7/18/98.
Severe back pains with leg spasms and inability to walk ,7/22/98.
Small skin abrasion left foot, 9/18/98, 9/19/98.
Gross tremors, 9/21/98, 10/9/98.
Acne, 9/23/98.
Left foot ulcer, 11/27/98.
Small bruise reaction right foot, 12/10/98, and mild foot sprain
12/11/98.
Flu symptoms/cold, 12/23/98.
History of physical abuse by
mother, sexual abuse as a child and physically abusive adult relationships.
History of partial deafness in
one ear, almost completely (80% in the other).
CONCLUSION:
Medical records from 7/12/97 through 3/18/98 were reviewed and indicated the
examinee,
Corrections
with a sentence of 15-17 years for four counts of lewd and lascivious
behavior
with a child and on 2/17/99 had lumbar diskectomy and fusion as
treatment for a large left disc protrusion (herniated nucleus pulposus) L5-S1 with
associated
small disc protrusions from L2-3to L4-5
(MRI 9/3/98) with concurrent
history
of chronic lower back pain syndrome with left L5-S1 radiculopathy
beginning
in 1993 with progressive decompensation since first seeking Emergency
Room
evaluation on 10/17/97
for back symptoms which, at that time, were felt to be
secondary
to lumbosacral degenerative disc disease and an obvious chronic
deformity
in the pelvic area.
Prior to
confinement at the Department of Corrections the examinee had a history of
anorexia nervosa, polysubstance dependence in a controlled environment
(marijuana, cocaine inhalation, alcohol), personality disorder with antisocial
obsessive borderline traits, history of physical abuse by her mother, sexual
abuse as a child and physically abusive adult relationships and notes (8/31/98,
Ingram) having partial deafness in one ear and almost completely (80%) in the
other. Moreover, the examinee is
presently being treated for a bipolar disorder with modulation from depression
to mixed hypomania, treated with various medications which
have included Depakote, Mellaril, Ativan and Vistaril.
Throughout
her confinement at the Department of Corrections, the examinee has had mental
health sessions approximately biweekly and, for the most part, has been stable
with difficulty sleeping, fluctuations in weight and periodic side effects from
medications.
Also,
during confinement at the Department of Corrections, the examinee has had an
annual upper respiratory infection though the majority of her visits to the
Emergency Room were apparently a consequence of her symptoms of chronic low back
syndrome with left lumbar radiculopathy, eventually culminating in lumbar
diskectomy and fusion on 2/17/99. The
single incident of a possible seizure/fall (7/18/98) with incontinence is as yet
not completely understood in the context of her condition though may have been a
side effect of medication or result of increased pain.
The
examinee was also treated for acne.
As
a consequence of an underlying chronic lower back condition, prior to lumbar
diskectomy and fusion on 2/17/99, the examinee was progressively unable to
maintain her culinary work activities, comfortably lift, push, pull, stand or
walk and periodically would have to sit down to relieve discomfort or squat
during prolonged standing. The
examinee also required a bottom bunk, double mattress, low bunk, special shoes,
anti-inflammatory and muscle relaxant medications and bed rest.
Subsequent
to lumbar diskectomy and fusion on 2/17/99, as of 3/15/99, the examinee noted
her back was much better than during the previous five years, and this has had a
significantly positive effect on her moods (3/15/99).
On 3/18/99 Dr. M.D.,
psychiatrist, noted the examinee's mental status was stable, mood good, and she
was recovering well from back surgery and medications were effective without
side effects.
PERMANENT FUNCTIONAL IMPAIRMENT
RATING BASED ON THE AMA GUIDES TO THE EVALUATION OF PERMANENT IMPAIRMENT, 4TH
EDITION:
When combined and rounded to the
nearest value of 0-5, this examinee has a permanent injury with a permanent
functional impairment rating of 10% to the body as a whole as a consequence of
her chronic low back syndrome with left lumbar radiculopathy for which she was
treated with lumbar diskectomy and fusion on 2/17/99.
MEDICAL
OPINION WITH REGARD TO MEDICAL RECORDS CASE REVIEW
With
a greater than 50% degree of medical certainty this examinee's post surgical low
back syndrome in conjunction with her psychiatric predisposition will have the
effect of requiring modification of the examinee's daily activities.
RECOMMENDATIONS:
In my opinion, by review of medical records only, the examinee should
maintain a daily
and Thera-Band stretching in conjunction with progressive musculoskeletal
rehabilitation to
develop an acute
therapy, hydrotherapy
anti-inflammatories, muscle relaxants and psychotropic medication as needed to
diminish pain, extend
anesthetic/cortisone trigger point
therapeutic benefit. The
examinee
support cushion and consider a
physically stressful activities.
With
regard to the examinee's psychiatric history of cyclothymia, anorexia nervosa,
polysubstance dependency, personality disorder, bipolar disorder and history of
physical and sexual abuse, she should continue with psychiatric management and
treatment which may require ongoing medication, counseling and individual and
group psychotherapy.
With
regard to the examinee's history of a possible seizure, should she develop
recurrent symptoms, an EEG, blood tests including but not limited to complete
blood count and chemistry profile, urinalysis, MRI of the brain and neurologic
consultation would be recommended.
With
regard to the examinee's history of partial deafness in one ear almost
completely (80%) in the other, an audiometric and tympanometric study in
conjunction with an evaluation by an otolaryngologist would be recommended.
This medical evaluation
was based solely on the medical records reviewed from 7/12/97 through 3/18/99.
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
drkalin@drkalin.com
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