ATT: Ms. Jacobson
John Alden Ins.
3884 River Rd., Suite 680
Temple City, CA 92248

Dear Ms. Jacobson,

The following is a medical/legal evaluation of injuries sustained on 04/17/97 by Joe McGee during the course of his employment at Johnson Enterprises.

The following permanent impairment evaluation was performed according to the criteria and methodologies of the AMA Guides (American Medical Association Guides to the Evaluation of Permanent Impairment, 4th edition, revised June 1993).

In utilizing the AMA Guides to evaluate a patient's permanent impairment, doctors are provided with a standard framework and method of analysis, by which he or she can evaluate, report on and communicate information regarding the permanent impairment of a patient.

History:
The patient is a 25 year old, male. His date of birth is 09/09/72; his social security number is 619-26-7721.

Initial History of Injury:
Mr. McGee's injury occurred while lifting an object from a surface about 1 to 2 feet off the ground. The object he lifted that caused the injury weighed approximately 40 to 60 pounds. The patient stated that his position was bent over at the waist when the injury occurred. He stated that a sharp pain came on immediately following the injury. Mr. McGee did report this injury in writing while at work. He has seen another healthcare provider since the injury occurred.

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Review of Medical Records Submitted To This Office:
Doctor's first report of occupational injury dated April 17,1997, signed by John Jones, M.D.. The date of injury was indicated as April 17,1997. Objective findings included: decreased range of motion due to severe pain; normal motor and sensory; intact DTR +2; cervical spine positive for percussion and touch tenderness; Diagnosis: Cervical Spine Sprain/Strain. Total temporary disability was given until May 1,1997.

Subjective Complaints:
Mr. McGee stated that he is experiencing:
1: constant (76 to 100% of awake time) muscle spasm in the neck. He rated the pain 10/10 using a visual analog scale with 10 being extreme pain. The symptoms seem to be aggravated by lying down and causing difficulties with driving a car. The patient stated that the pain is radiating into the left hip.

2: frequent (51 to 75% of awake time) pain across the right shoulder. He rated the pain 7/10. The symptoms seem to be causing difficulties with normal sleeping.

3: intermittent (26 to 50% of awake time) increased tension throughout the body. He rated the pain 4/10.

4: intermittent (26 to 50% of awake time) stiffness in the mid back with a visual analog scale rating of 3/10. The symptoms seem to be aggravated by prolonged sitting positions.

Deep Tendon Reflex Testing:
Right Biceps- normal; Left Biceps- hypomobile; Right Triceps- normal; Left Triceps-hypomobile; Left Patellar- normal; Left Achilles- normal.

Pathological Reflex Testing:
Pathological Reflexes were tested and indicated Upper Extremity Hoffman's to be present. Lower Extremity Babinski's to be present.

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Sensory Perception:
Areas of anesthesia were noted within the dermatome areas corresponding to the nerve root levels of T10 on the left. Areas of hypoesthesia were noted within the dermatome areas corresponding to the nerve root levels of L3 on the left.

Cranial Nerve Testing:
Examination of the cranial nerves revealed the following: A normal sense of smell. There was a normal response to both direct and indirect light as well as accommodation reflexes. Extraoccular movements were not performed satisfactorily indicating a possible involvement of the third, fourth or sixth cranial nerves. The fifth cranial nerve(trigeminal) revealed abnormal movements. The patient was able to perform the normal range of facial movements, no asymmetry or other abnormalities were noted. The tuning fork test showed the eighth cranial nerve (acoustic) to be normal. Examination of the throat revealed no abnormality of the pharyngeal musculature. Examination of the laryngeal musculature for asymmetry deviation and/or atrophy indicate a possible abnormality involving the tenth cranial nerve. The shoulder shrug was performed well revealing the eleventh cranial nerve to be normal. Examination of the throat revealed no deviation, atrophy or asymmetry of the tongue.

Coordination Testing (Proprioceptive System):
Rhomberg test was (-) negative. Finger to nose test was performed normal. Finger to finger test was performed poorly. Heel walking was performed normal. Toe walking test was performed normal.

Orthopedic Evaluation:
(+) positive Max. Compression with minimal pain at 20°.
This test is performed with the patient seated. The patient is then instructed to first laterally flex the cervical spine (maximally) and then simultaneously rotate the head ipsilaterally to the shoulder. Eliciting radicular pain constitutes a positive test. (This test can be performed passively). Significance of Maximum Cervical Compression Test: Root compression secondary to narrowing of the IVF.

(+) on the left Jackson's Comp. with radiation to the (L) shoulder.
This test is conducted while the patient is seated. The patient is directed to flex the cervical spine laterally toward the shoulder as far as tolerable. The examiner then exerts downward, axial pressure over the cranium. The test is repeated to the opposite side. A test result is positive if pain/discomfort, and/or radiation along a nerve pathway occurs on the side being compressed. The distribution of pain and altered sensation can give some indication as to which nerve root is involved. It is not uncommon to have a positive test on the side being compressed and pain ''finding'' on the opposite side. Significance of Jackson Compression Test: Nerve root compression.

(+) positive Valsalva.
The Valsalva test is conducted by requesting the patient to bear down as it straining at stool by way of forcible exhalation against a closed glottis. If this action caused increase of spinal pain and radicular neuralgia, the test is positive.

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(+) positive Bakody's Sign with minimal pain.
Bakody's test, also known as the Shoulder Abduction Test is conducted with the patient sitting or Lying. The arm is actively or passively elevated through abduction so that the hand or forearm rests on top of the head. A decrease in, or relief of, symptoms indicates a cervical extradural compression problem such as a herniated disc, or nerve root compression usually in the C5-C6 area. If a patient presents holding his/her hand on the top of his head to relieve pain, its called JOLLY'S SIGN.

(+) positive Codman's Drop Arm.
Procedure: The sign is present when, with a shoulder complaint, the patient's arm can be passively abducted with no pain. But should the examiner suddenly remove the support at some point above the horizontal, making the deltoid contact suddenly, there is a hunching of the shoulder due to the absence of rotator cuff function as the patient attempts to maintain the abduction. Significance: Rotator cuff tear - Rupture of the supraspinatus tendon.

(-) negative Yergason's Test.
Procedure: The patient is seated on an examining table, the examiner stands facing the patient and slightly lateral to the upper limb to be tested. The patient with palm facing upward, makes a fist then bends the elbow to approximately ninety degrees. It digitally palpates over the ipsilateral bicipital groove while the other hand clasps the patient's fist. The patient is then directed to put approximately fifteen to twenty pounds effort in maximally flexing the elbow while the examiner keeps the elbow stable and at the same time internally and externally rotates the arm. The test is positive when a painful palpable and/or audible snap or click is elicited as the bicipital tendon slips in and out of the bicipital groove. Significance: Loss of stability of the Biceps

(+) positive Adson's with minimal pain.
The Adson's test is conducted with the patient sitting upright. The examiner then palpates the radial pulse. The patient is asked to rotate the head to the side of the limb being tested, also to extend the neck as much as possible, take a deep breath and hold it. The test is positive if the pulse is occluded or is dampened. The maneuver may be repeated with the patient turning his head to the opposite direction. The test may be positive if neurovascular compression of subclavian artery and/or brachial plexus; commonly caused by scalenus anticus, cervical rib and thoracic outlet syndromes. Note: Only 2-3% of patients with thoracic outlet syndrome will have positive occlusion of radial pulse.

(+) positive Kemp's Test with slight pain.
The patient in this test is either seated or standing. The examiner stabilizes the pelvis with one hand while exerting extension, rotation and lateral bending to the trunk and lumbar spine. A positive finding is lower back pain with radiation into the leg. This distinction should be noted here. Significance of Kemp's Test: Disc prolapse or protrusion. The discal material maybe medial, lateral or inferior and differentiated by additional orthopedic signs, test or maneuvers. Lower back pain without radiation is indicative of posterior facetal irritation, pericapsulitis or lumbar strain.

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Palpation:
Tenderness: the cervical region moderate. Subluxations were found at: C3 and C4 anterior, rotation; T5 and C6 left, superior rotation. Joint Mobility: C4 hypermobile. Non-spinal Tenderness: suboccipital revealed moderate spasm; trapezius revealed moderate spasm. Muscle Tone: posterior cervical rigidity (grade +1). Muscle Strength: deltoids good (grade +4).

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Based on today's examination, previous records and the patient's subjective complaints, this patient is considered, for all practical purposes, to be permanent and stationary. The following are the factors of permanent disability.

Objective Factors of Permanent Disability:
1. History of an industrial injury on 04/17/97.

2. Chronic upper trapezius and levator scapulae muscular atrophy.

3. Seriously decreased cervical ranges of motion.

Subjective Factors of Permanent Disability:
1. Chronic moderate upper lumbar pain that seems to be worse while lifting. The patient specifically stated that he can't lift above 15 to 20 pounds. This pain seems to increase with repetitive bending and rotation.

2. Frequent pain across the right shoulder. This pain is relieved by walking. Sitting in one place for more than 15 to 30 minutes causes pain throughout his shoulders and upper arm.

AMA Impairment Ratings:
The Range of Motion model of the AMA Guides is one of the recommended methods for the evaluation of permanent impairment of the spine. The below spinal whole-person range of motion impairment is derived from chapter 3, tables 72-82 of the AMA Guides.

The measurements used below present an average of three measurements obtained with +/- 10% or 5° of each other.

Cervical Region Impairment: (from a neutral position)

Combined Cervical Whole-Person Range of Motion Impairment: 7%

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Lumbar Region Impairment:
The sum of the sacral(hip) flexion and sacral(hip) extension was within 15 of the straight-leg raising test on the tighter side. Therefore the below lumbar flexion/extension impairments are valid.

Combined Lumbar Whole-Person Range of Motion Impairment: 3%

Combined Spinal Whole-Person Range of Motion Impairment: 10%

Work Analysis:
The patient states that his job included activities such as bending and stooping. At Work, Mr. McGee was regularly required to lift between 60 to 80 pounds. The patient further explained that the dynamics of his job were such that he was regularly required to bend from the waist while lifting various objects. He did state that his hands were subject to repetitive movements such as firm grasping with both hands. Mr. McGee reported that in terms of an 8 hour work day, he is regularly required to perform activities such as: Sitting - 1 to 2 hours. Walking - 4 to 6 hours.

Work Restrictions:
The consistency of the data, from the evaluation of the patient's subjective complaints and the objective examination, revealed that Mr. McGee will be able to return to work with modified duties.

Based on the subjective and objective findings in this case, I would restrict lifting objects over 25 pounds.

The patient may be regarded as a Qualified Injured Worker.

Causation:
Mr. McGee's symptoms appear to have come on as a result of a work related accident consistent with the one described in this report. His history, subjective and objective findings, and radiographic examination show evidence, from a medical viewpoint, that his condition is due to the current injury only and even though similar symptoms from a previous condition were reported, there is no evidence of any contributing factors.

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Apportionment:
None.

Reasons For The Opinion:
Based on the objective findings of the physical examination, review of the provided records and the subjective complaints as stated by the patient, I have concluded that Mr. McGee has reached a permanent and stationary status and has objective and subjective factors of permanent disability as outlined above.

Pursuant to Labor Code #4628, the following declaration is made.

I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to the information, I declare under penalty of perjury that the information accurately describes the information provided to me and except as noted herein, that I believe it to be true.

Executed on 05/06/97, at San Luis Obispo.

Sincerely,

Mark Bagby, D.C.

You Treat The Patients, We'll Handle The Paperwork!