Independent Medical Evaluation Transcription Sample Report

INDEPENDENT MEDICAL EVALUATION/EXAMINATION (IME) SAMPLE REPORT

DATE OF INDEPENDENT MEDICAL EVALUATION/EXAMINATION (IME):  MM/DD/YYYY

LOCATION OF INDEPENDENT MEDICAL EVALUATION/EXAMINATION (IME):  XYZ

INTRODUCTION: The claimant was informed that the independent medical evaluation was for evaluative purposes only, intended to address specific injuries or conditions as outlined by the claims manager, and was not intended as a general medical examination.

The claimant was asked at the time of the examination not to engage in any physical maneuvers beyond what he was able to tolerate or which he believed were beyond his limits or which could cause harm or injury. The examinee was instructed that the evaluation could be stopped at any time and not to allow the evaluation to continue if it caused pain.

HISTORY OF PRESENT COMPLAINT: The claimant is a (XX)-year-old right-hand dominant (XX) who was working for (XX) on MM/DD/YYYY. That day, he fell off a ladder and had immediate pain in his left arm, right wrist and right kneecap.

He was taken to (XX) Hospital where he was diagnosed with fractures of the left forearm, right wrist and right patella. That same day, he underwent open reduction and internal fixation of those body parts. He was maintained in the hospital for five days.

Following that, he went to physical therapy for about three months. He said he got along reasonably well with the exception of his right hand and wrist. He continued with significant pain, numbness and loss of function.

Based upon that, in MM/YYYY, he underwent right wrist hardware removal with carpal tunnel release. Since that time, he had no additional treatment. He says his symptoms are no longer changing.

CHIEF COMPLAINTS/ CURRENT CONDITION: Right hand and wrist pain, numbness and loss of function and right knee pain.

Today, he tells me the number one problem is the right hand. He has numbness and weakness with loss of right wrist function.

His number two problem is his right knee pain. He describes that as a deep aching pain. It is made worse with knee motion. He would rate that at a 5 on a scale of 0 to 10.

He specifically denies any problems with his neck or shoulder.

His past history is significant for a right scaphoid fracture in (YYYY), which was treated with open reduction and internal fixation.

CURRENT WORK STATUS:

Occupational History: The claimant had worked for (XX) for six months at the time of his injury.

PAST MEDICAL HISTORY:
Conditions: Negative for major medical illnesses.

Operations:
1. In (YYYY), right scaphoid open reduction and internal fixation.
2. In (YYYY), right and left forearm and right knee open reduction and internal fixation.
3. In (YYYY), right wrist hardware removal.

Allergies: NKDA.

Current Medications:
1. Hydrocodone.
2. Gabapentin.
3. Flexeril.

Substance Use: He does not take other drugs.

Tobacco: The claimant smokes a pack a day.

Alcohol: He drinks alcohol socially.

SOCIOECONOMIC HISTORY:

Marital Status: The claimant is single with no children.

Education: The claimant has graduated from high school.

Military Service: The claimant was never in the military.

Hobbies:
1. Sports.
2. Reading.
3. Hunting.

RECORD REVIEW: The first medical record available for my review is a radiographic report from (XX) dated MM/DD/YYYY. It is an x-ray report regarding the right humerus. It is noted to be negative for fracture.

A second x-ray report that same day, of the left forearm, reveals transverse fractures of the mid distal radius and ulna. X-rays of the right forearm indicate a comminuted fracture of the distal radius. X-rays of the left wrist are negative. X-rays of the left wrist show the distal radius and ulna fracture. X-rays of the right hand show the distal radius fracture.

X-rays of the right knee show a displaced patellar fracture.

MM/DD/YYYY x-ray report shows evidence of a postoperative screw across the scaphoid.

On MM/DD/YYYY, the claimant was seen by Dr. John Doe at (XX). This was for followup on a bilateral wrist injury. His assessment was one of right patellar fracture, status post ORIF, right both bone forearm fracture, status post ORIF, and right distal radius fracture, status post ORIF with right great toe distal phalanx fracture. He recommended ongoing physical therapy.

On MM/DD/YYYY, the claimant was seen by Dr. Jane Doe of (XX) in (XX). This was for treatment of algodystrophy of the hand. He was begun on a pain management program.

On MM/DD/YYYY, the claimant was seen in followup by Dr. (XX) Doe. This was for multiple fracture followup as well as the numbness of the right hand. He recommended EMG testing.

On MM/DD/YYYY, the claimant underwent EMG testing, which revealed denervation of the median innervated muscles of the hand. There was severe right carpal tunnel noted.

On MM/DD/YYYY, the claimant was seen in followup by Dr. (XX). His assessment was carpal tunnel syndrome. He recommended surgical decompression.

On MM/DD/YYYY, the claimant was again seen in followup by Dr. (XX). He had an injection of the hand but was still having a good deal of numbness.

On MM/DD/YYYY, the claimant was seen in followup by (XX). He continued to have right hand numbness. Further conservative treatment versus surgery was reviewed.

On MM/DD/YYYY, the claimant was seen in followup by Dr. (XX). He continued with significant right forearm pain and numbness. Carpal tunnel release was again discussed.

On MM/DD/YYYY, repeat EMG testing was done, which showed again severe carpal tunnel in the right wrist.

On MM/DD/YYYY, the claimant was seen in followup by Dr. Knight. They reviewed the EMG studies. He recommended hardware removal and carpal tunnel release.

On MM/DD/YYYY, the claimant was seen for followup visit by Dr. (XX). He was noted to still have significant pain and numbness. He was informed by Dr. (XX) that recovery may take six months or more.

On MM/DD/YYYY, the claimant was seen in followup by Dr. (XX). He continued with significant right hand pain, numbness and weakness. The diagnosis was one of algodystrophy. He was again treated medically.

That completes the medical records available for my review.

PHYSICAL EXAMINATION: The claimant is right-hand dominant.

Age: (XX) years
Height: 5 feet 7 inches tall
Weight: 122 pounds

In general, the claimant was noted to be a pleasant gentleman who appeared his stated age.

The claimant arose easily from a chair. He stood erect. His gait pattern was normal. He was able to heel and toe walk.

Physical examination of the right knee revealed the skin to be intact. There was a normal knee contour. There was a well-healed anterior incision.

Bilateral knee range of motion testing shows:

The knee was stable to varus and valgus stressing. There was a negative anterior drawer sign. There was a negative posterior drawer sign. There was a negative Lachman’s maneuver. There was patellofemoral crepitance with range of motion.

Motor strength in both lower extremities was 5/5 throughout. There was slight subjective paresthesia about the incision inferiorly.

There was no atrophy or fasciculations.

The knee and ankle reflexes were 2+ and symmetric. There were 2+ dorsalis pedis and posterior tibial pulses.

Physical examination of the left arm revealed the skin to be intact. There was a normal arm contour. There was a well-healed surgical incision.

Elbow range of motion testing shows:

Wrist range of motion testing shows:

Motor strength in the left arm was 5/5 throughout.

Two-point discrimination in the left hand was less than 6 mm in all fields

Bilateral pinch and grip strength show:

Physical examination of the right elbow revealed the skin to be intact. There was normal elbow contour. There was no point tenderness.

Physical examination of the right wrist revealed a well-healed volar scar. There was tenderness over that scar. There was a positive Tinel’s sign at the wrist.

Two-point discrimination in the thumb, index, long and radial aspect of the ring finger was greater than 20 mm. Two-point discrimination on the ulnar aspect of the ring finger and little finger was 6 mm.

There were 2+ radial pulses.

Motor strength of both upper extremities with the exception noted of the right hand was 5/5 throughout. There was no atrophy or fasciculations. The pinch and grip strengths were noted as above.

DIAGNOSTIC STUDIES:
1. X-rays of the right distal radius dated MM/DD/YYYY show well-positioned volar plate with multiple-screw fixation. The fracture alignment is nearly anatomic.
2. X-rays of the right foot from that date show evidence of a distal phalanx fracture of the right great toe.
3. X-rays available for review of the right patella dated MM/DD/YYYY show anatomic reduction with two interfragmentary screws in place in the patella.
4. X-rays of the left forearm dated MM/DD/YYYY show radius and ulnar plates in place with anatomic fracture reduction and apparent healing.
5. X-rays of the right distal radius dated MM/DD/YYYY show solid healing with appropriate alignment of the volar plate screw device.

That completes the imaging studies available for my review.

DIAGNOSES AND RELATIONSHIP:

1. Right intra-articular distal radius fracture, causally related to MM/DD/YYYY work injury.
2. Right wrist traumatic carpal tunnel, causally related to MM/DD/YYYY work injury.
3. Left distal radius and ulnar fractures, causally related to MM/DD/YYYY work injury.
4. Right great toe distal phalanx fracture, causally related to MM/DD/YYYY work injury.
5. Right patellar fracture, status post open reduction and internal fixation, causally related to MM/DD/YYYY work injury.