Independent Medical Evaluation by Douglas W. Martin

Author:Douglas W. Martin
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Ms. Valorie Grant is a 57-year-old white female who presents herself today for an Independent Medical Examination, at the request of Chris J. Attorney, attorney-at-law, surrounding claims of injury to her right shoulder. The letter that I have received from Mr. Attorney would also seem to imply that she is claiming a back injury. However, when I reviewed this with the claimant today, she seemed extremely surprised about any spinal problems and stated that it was her understanding that the issue was simply with respect to her right shoulder.

This lady reports that she believes that she began to experience problems with respect to right shoulder pain several years ago (she is unable to give me a specific date) where she was carrying a tray of food into a freezer at her work place, known as Timmy’s Catering, when she had a slip injury and fell with her right arm into a rack. She, apparently, did not go all the way to the ground. The medical record would suggest that this incident was taken care of by Dr. Strittholt in 2005, wherein his record would indicate an evaluation on October 24, 2005, which resulted in treatment with a shoulder injection.

The lady reports that she did have good improvement with respect to the injection, at that point. The medical record would also suggest that the lady underwent advanced diagnostic imaging of her right shoulder with an MRI scan on November 15, 2005 showing mild acromioclavicular joint hypertrophy and degenerative changes with tendinosis.

Over the course of the next several years, the lady then states that she had on and off exacerbations of right shoulder pain. The medical record would suggest that yearly thereafter she presented back to Dr Strittholt for right shoulder pain which was basically treated with repeat injections. This was done in 2006 and then also again in 2007. In early 2008, she had another reported problem of exacerbation which was treated with injection and then the lady had another problem of reexacerbation in October of 2008 which led to yet another injection. However, apparently, that did not necessarily improve her symptoms, as it had prior. In April of 2009 she had more problems and a repeat MRI scan was done. Partial thickness tearing of the rotator cuff appeared to be present with, again, the acromioclavicular joint hypertrophy, which was noted on the prior MRI scan. An extensive tendinitis signal was noted.

After this point in time, there was some discussion about options for care. But, eventually, on July 21, 2009, the lady underwent a shoulder arthroscopic procedure. A subacromial decompression with rotator cuff repair was performed.

The lady, apparently, did reasonably well with surgery, but in discussion with her today, she reports that it took longer than what she had hoped. She states that she had some postoperative physical therapy that was helpful.

She reports that she continues to have some degree of issues concerning her right shoulder. She reports that it is better with the surgery than what it was. The main issue that she seems to have is with respect to overhead type of activity with her right arm.

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