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Embed code for: CARRANZA, ROBERTO-IME--091616
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September 16, 2016
Mr. John Huskin
Thomas, Thomas, Hafer, LLP
1829 Reisterstown Road
Baltimore, MD 21208
RE: CARRANZA, ROBERTO
Claim #: 380804
Dear Attorney Huskin:
I have been asked to perform an Independent Medical Examination on Roberto Carranza. The examination was performed in the Hagerstown Office of Mid Maryland Musculoskeletal Institute on 09/12/16.
Prior to my examination, the claimant signed the information instructions about your IME form. He also completed the Independent Medical Evaluation questionnaire. This was done with the assistance of the interpreter, Joseph Hill.
I reviewed the information on the IME questionnaire.
The claimant states that on 03/17/16 he was working. He was holding a heavy object and then the cable attached to the object was raised suddenly without his knowledge and it pulled his arms away from his body forcefully. He complains of problems with his elbows, shoulders, upper back, neck, chest and underneath the axillary areas. He also has problems with nerves, tendons and muscles. He said he is not able to hug his son.
His pain rates from 5-6/10 in intensity, but sometimes 9/10 in intensity. Before the injury, he was able to play sports, now he is only able to lift 20 lbs.
He complains of the pain being strong and burning. He said the pain will
Re: Roberto Carranza
be present without him doing anything. He has the pain constantly.
He says at this time he cannot lift anything heavy and cannot mow the lawn.
He was employed by Jan Gregory at Digging and Rigging, Inc. He had worked there for 4-5 years.
His has a past history of appendicitis. He injured his foot recently falling over furniture. His past medical history includes a history of diabetes, hypertension and heart disease.
I had the opportunity to perform a physical examination. The claimant was seen and examined. The examination was conducted with the interpreter assistance of Mr. Hill. I took my own history and history that I received was that on 03/17/16 he was balancing a counterweight, he was hugging the counterweight and the cable was raised quickly and his arms were thrown apart. At the time of my examination, he complained of pain in his chest, back, shoulders, underneath both arms, both elbows, back of neck and he had pain in the back of the neck. He described burning around the shoulders, elbows. He says he was having pain on the elbow bones. He also said he had pain in the scapula area posteriorly. He said he got a little bit better with physical therapy. I asked him what he could now that he couldn’t do before and he said he could raise his arms, but that it “hurt.” He denied any past problems with these areas of his body.
The clinical examination was recorded. His neck revealed full ROM. He complained of pain. There was no spasm. The examination was performed with his tee shirt removed. He was noted to be well muscled in his chest and upper extremities with no evidence of visible muscle atrophy. DTRs in the upper extremities including triceps, biceps, brachioradialis were 1+ to trace right and left. Forward flexion left shoulder 160 degrees, abduction 130 degrees, external rotation 80 degrees, internal rotation to the sacrum. Forward flexion right shoulder 150 degrees, abduction 130 degrees, external rotation 80 degrees, internal rotation to the sacrum. Sensation was intact. He says he “feels everything.” Girth measurements in right upper extremity revealed symmetrical girth measurements 5-inches proximal to the lateral epicondyle 16,” girth measurements 4-inches distal to the lateral epicondyle 13-1/4” right, 13” left. The claimant is right hand dominant. His pulses were intact. Motor strength in all muscle groups of the upper extremities was graded 5/5 including the intrinsics of the hands. There was no muscle atrophy. He had tenderness over both AC joints. No crepitus was noted over the shoulder. He had no tenderness over the olecranon. He had pain to palpation in the trapezius area. Elbows revealed full ROM, full flexion/extension of the elbows, full pronation and supination. He had tenderness in his chest wall, tenderness in the axillary areas of both shoulders. He had tenderness in the pectoralis muscles right and left and had tenderness in the humeral head area anteriorly.
At the end of the examination I asked the claimant if there was anything else we had not
Re: Roberto Carranza
discussed and he said no.
HEALTH AT WORK
The claimant was seen on 03/22/16. Again, the history was that a crane opened an object quickly and pulled his arms out to the side. He complained of pain in both shoulders and numbness in his fingers. He also complained of pain across the chest. He said he had paresthesias in the 4, 5 fingers of both hands. The clinical examination revealed mild generalized tenderness to touch. His grip strength was “slightly decreased.” He was diagnosed with a muscle strain. He was placed on a lifting restriction of 10lbs and was to be off from work for a few days.
On 03/24/16 he was seen again at Health at Work. He continued to complain of pain. He had increased pain in his arms, shoulders, neck, shoulder blades. Again his clinical examination was recorded. It did not reveal any specific neurologic deficits.
On 03/31/16 he was seen again at Health at Work. His condition was virtually unchanged. He was noted to have decreased grip strength, bilateral impingement signs in the shoulders. He was diagnosed with a muscle strain, trapezius strain, a labral tear of both shoulders. He was placed on Vicodin. He was to be off work and referred to orthopaedics.
On 04/04/16 he was seen for the last time at Health at Work. He had tenderness, which was described as moderate over both trapezius and upper extremities. His ROM was limited. He was referred to orthopaedics.
DR. SCOTT WORRELL
On 04/11/16 he was seen by Dr. Scott Worrell, the injury was reviewed. The claimant states that while he was controlling a counterweight metal for a crane, as it was being unloaded. He said he has to hug the metal counterweight to stabilize them from falling. The crane operator pulled the crane cable too fast and the bars rapidly destabilized forcing both arms apart with force. He complained of pain and discomfort in both upper extremities. His clinical examination revealed guarded testing involving Near test, biceps test, Speed’s test, labral test and biceps load. There was tenderness throughout the biceps and the antecubital region. Cubital tunnel percussion test was “a soft positive.” He had tenderness in the forearms. He was felt to have muscle strains in the upper extremities. He was placed on Skelaxin and Voltaren XR. He was placed off work.
On 04/25/16 he was seen again by Dr. Worrell. He continued to be seen and followed. His clinical examination was recorded. No specific neurologic deficits were noted. His grip strength
was decreased 4-/5. Therapy was discussed, but Dr. Worrell wanted to wait a few weeks.
On 05/27/16 he was seen again in follow up by Dr. Worrell. History was reviewed. The clinical examination was recorded. Belly press test was negative. Resisted external rotation strength was “quite good.” Resisted wrist flexion/extension was painless and had good strength. He had tenderness about the elbows. He had diffuse tenderness in the shoulder girdle area. He was diagnosed with right shoulder pain, left shoulder pain, strain of the muscles of the rotator cuff and other muscle strains. It was felt that the claimant was “recovering fairly well.” He still had pain. MRIs were suggested of both shoulders.
On 06/10/16 Dr. Worrell saw the claimant again. His clinical examination again revealed diffuse tenderness, distal motor function was well preserved. He was continued on Voltaren and placed on Neurontin.
He was to be seen again 07/15/16.
MARGARET GISE PT
On 05/20/16 the claimant was seen in physical therapy, EMGs were pending.
An EMG/NCS was performed on 05/25/16. The study revealed findings which indicated there was no evidence for neurologic deficits. The EMG/NCS studies were entirely normal. All examined muscles showed no evidence of electrical instability. The impression from Dr. Marks
who performed the study was that the EMG/NCS of the bilateral upper extremity muscles and nerves was normal.
An MRI of the right shoulder was performed on 06/04/16. This revealed a moderate rotator cuff tendinopathy, no high grade partial or full thickness tear was detected. Moderate AC joint arthrosis was noted. Mild glenohumeral joint degenerative changes were noted. No derangement was noted in the pectoralis major and minor muscles.
An MRI of the left shoulder was performed on 06/04/16. Again, no full thickness rotator cuff tear was noted. There was a small high grade undersurface partial thickness supraspinatus tendon tear in the left shoulder.
Otherwise the findings revealed no acute significant pathology in the left shoulder.
Re: Roberto Carranza
CONCLUSIONS & OPINIONS
Based on review of the records and my clinical examination, the claimant complained of soft tissue problems involving his neck, upper back, shoulders, elbows and arms as a result of an injury 03/17/16. No specific neurologic abnormalities have been identified on the EMG/NCT study. No acute structural abnormalities have been noted on the claimant’s shoulder MRIs. The findings on the MRIs of the shoulders are chronic in nature and are consistent with the claimant’s history of manual labor.
I believe at this time the claimant has completely recovered from the work related condition from 03/17/16. Again, his clinical examination reveals no objective findings. The diagnostic studies performed also revealed no objective findings.
The claimant has reached maximum medical improvement. Again, his clinical examination reveals no significant neurologic or structural abnormalities in his neck, upper back, scapulae, shoulders, forearms, elbows or axillae.
Using the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition, as a guide, which included consideration for pain, atrophy, weakness, loss of function and loss of endurance, the claimant has a 0% permanent partial impairment as a result of the accident of 03/17/16. He has no structural or neurologic deficits based on his clinical examinations as well as the diagnostic studies including the EMG/NCS and his MRIs. The findings on the MRIs are chronic in nature and would not restrict him from performing the normal activities of his occupation, which he has had done for 4-5 years prior to the injury date. The claimant has subjective complaints of pain, however, the complaints of pain are not associated with any clinical examination findings. The claimant has no objective findings which support the claimant’s complaint of pain. He has no demonstrable atrophy. He has no documented objective loss of function or use and his clinical examination does not support any loss of endurance since his motor strength is normal and has no muscle atrophy. His subjective complaint of pain is not correlated with any objective findings and therefore does not support any impairment.
All of the opinions in this report have been made within a reasonable degree of medical certainty.
This examination and report are done solely as an Independent Medical Evaluation and no doctor/patient relationship should be deemed to exist by virtue of this evaluation. I introduced myself and explained the reason for the visit prior the visit and I asked the claimant at the end of
the visit to please add any information that I did not specifically question him about during the examination.
Robert J. Cirincione M.D.
Douglas S. Rockwell, Esquire
April 17, 2002
RE: Daniel Delozierrved. He was continued on Voltaren and placed on Neurontin.
An EMG/NCS was perform