1. science
2. medicine
3. surgery

Impairment
Rating
Specialists
John W. Alchemy, MD, AAFP, QME, CIME
Impairment Rating Specialists, Unlimited
John W. Alchemy, MD, A Medical Corporation
Validated Certified Final Comprehensive Written Ratable
Date of Birth: 10/2/75
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Employee: Doe, John
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Permanent and Stationary Report/ML-104
Social Security #: 123-45-6789
Date of Evaluation: 2/17/11
Date of Injury: 1/15/08
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Adjuster: Jane Doe
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Insurance Carrier: ACME Inc.
Claim #: 00000-00000WC02
Examining Physician: John W. Alchemy, MD
Location of Examination: Anytown, CA 91234
Type of Examination: California Workers’ Compensation
Level of Examination: Comprehensive Written Ratable Permanent and Stationary Report,
Medical Legal Format.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Table of Contents
Executive Summary Statement ..........................................................Section 1
Preliminary Introduction & Exam Metrics ........................................Section 2
Description of Records Relied Upon .................................................Section 3
Identifying Employment Background Information ...........................Section 4
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Injured Body Location(s) & Mechanism of Injury ............................Section 5
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Prior Treatment Summary & Relevant Information ..........................Section 6
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Current Symptoms & Complaints ......................................................Section 7
Activity of Daily Living Affected by Injury ......................................Section 8
General Past Medical, Family & Social History ................................Section 9
Physical Examination Findings..........................................................Section 10
Summary Claim Diagnoses................................................................Section 11.
Summary Discussion and Opinion.....................................................Section 12.
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Decision Making and Impairment Calculations ................................Section 13
Final Claim Summary and WPI .........................................................Section 14
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Permanent Functional Restrictions ....................................................Section 15
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Causation............................................................................................Section 16
Future Medical Care ..........................................................................Section 17
Pain Assessment.................................................................................Section 18
Apportionment ...................................................................................Section 18
Displaced Worker Benefits & Vocational Rehabilitation ..................Section 19
Affidavit and Examiner Signature .....................................................Section 20
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Section 1. Executive Summary Statement
The applicant is referred today by Jane Doe of ACME Insusrance for evaluation
regarding left hip injury per cover letter document dated 2/2/11.
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Section 2. Preliminary Introduction & Exam Metrics
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Requested is cc of this report to Dr Bonesetter, MD. Orthopedics. 123 Civic Center Dr..
Anytown, CA 91234
.
Mode of Transportation to Exam: Self Drive
Additional Parties Attending Exam: None
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Request for Audio or Video Taping: None
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Exam Start Time: 0958
Exam End Time: 1108
Interpreter: (x)No ()Yes:
Disclosure to Employee:
1)The employee is informed that there will be no treating physician/patient relationship.
2)Information shared by the employee will be included in the examiner’s report.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
3)The employee should not engage in any physical maneuvers that may cause injury, and
that the employee should immediately report any discomfort encountered during the
examination.
Section 3. Description of Records Relied Upon
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Time: 127 Minutes
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# Pages:194 pages, two cover letters with report bundles from REMIF, Adjuster Jane
Doe, Dated 2/1/11 and 1/2/11.
The medical records are summarized below :
1. Job Duty for Equipment Mechanic II Reviewed. Administrative job description.
types.
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Heavy and varied mechanical repairs are outlined for fleet vehicles of various
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2. 12/13/10 Dr. James Dean, MD. Comprehensive Medicolegal Examination.
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History and chart reviewed. Exam normal hip motion. No atrophy of legs.
Straight leg raise negative, range of motion full. No additional imaging
performed. Diagnosis: Left hip pain. Cause is industrial. No further treatment. No
work restrictions. No apportionment. No impairment. Disability status has
reached maximum medical improvement
3. 8/10/10 Dr Bonesetter, MD. Orthopedics. PR4 History: Groin pull while lifting
pump with complaints left groin hip pain. Exam: pain with rom left hip. 8/17/09
x-ray degenerative changes. 5/21/09 MRI left hip labral tear. Diagnosis left hip
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
pain and left hip labral tear. No work restrictions. No comments on apportionment
or future care.
4. 8/10/10 Dr Bonesetter, MD. Orthopedics. Clinic note. Back at work doing well.
Still pain when sits on ischium. Points to ischial tuberosity and SI joint. Still pain
and weakness over adductors. Hip pain resolved. Has open comp injury left knee
and underwent arthroscopy but still has problems. Plan hip still with residual pain
but over time strength will get better. “we will make him permanent and
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follow him up on an as needed basis.”
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stationary and return him back to his primary care treating physician. We will
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5. 6/15/10 Dr Bonesetter, MD. Orthopedics. Clinic note. Adductor strain improving.
Exam nearly full painless range of motion. Slight tenderness over ischial
tuberosity. Doing well. Can return back to full unrestricted duty today. If he is
doing fine he will be made permanent and stationary.
6. 5/18/10 Dr Bonesetter, MD. Karen Smith, PA-C. Orthopedics. Clinic note. Follow
up. Doing much better. Restarted therapy. Ibuprofen tid. Continues full duty.
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Feels capable of doing full duties. Some pain in abductors. Left hip excellent
range of motion. Improving. Continue self care the therapy.
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7. 5/6/10 Dr Bonesetter, MD. Karen Smith, PA-C. Orthopedics. S/p left hip
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arthroscopy and debridement of labrum and synovium, chondroplasty acetabulum
and acetabular rim trimming on 8/23/09 by Dr. Bonesetter. Returned to dull duty
4/6/10 was doing well. Working on “light side”. Able to sit stand and walk
without limitations. Lifting limited to less than 30#. Anticipate return to usual and
customary work in future.
8. 4/6/10 Dr Bonesetter, MD. Karen Smith, PA-C. Orthopedics. Continue to
improve. No longer with acute pain. Continue to improve.
9. 4/6/10 Dr. Rita Nelson. Full duty per Dr. Bonesetter. Follow up Dr. Bonesetter.
Full duty 4/6/10.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
10. 3/23/10 Dr. Sharon Ruiz, D.C. Summary. Continues to feel better. Lumbar rom
full. Supine SLR without pain both sides. Glut medius and piriformis muscles are
guarded. Hip int/ext rotation without pain. Overall improved. Finish treatment and
follow up Dr. Bonesetter 2 wks.
11. 2/23/10 Dr. Rita Nelson. Request for records and follow up Dr. Bonesetter
outlined. Restrictions outlined.
12. 2/23/10 Dr Bonesetter, MD. Karen Smith, PA-C. Orthopedics. Some
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improvement. Still deep pain left buttock which is palpable and tender. Doing
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therapy. No bowel or bladder complaints. Occasional back pain in life but no
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issues with the back. Excellent range of motion. Diagnosis left hip piriformis
syndrome. Continue therapy and some chiropractic care Dr. Ruiz.
13. 2/9/10 Dr Bonesetter, MD. Orthopedics. Sick in bed coughing and felt significant
tightness over posterior lateral hip. Continues modified work. Left hip no change
in motion. Would benefit from therapy. Recheck 3 weeks and then release back to
full duty.
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14. 2/11/10 Dr. Rita Nelson. Consult for post operative physical therapy.
15. 12/30/09 Dr. Rita Nelson. Improved left hip pain after surgery. Full rom hip
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without joint discomfort. Follow up Dr. Bonesetter.
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16. 12/29/09 Dr Bonesetter, MD. Karen Smith, PA-C. Orthopedics. Continuing to
improve. Has been exercising. Excellent range of motion. Increase work activity.
17. 12/1/09 Dr. Rita Nelson. Follow up. Request for Dr. Bonesetter reports and
modified work outlined.
18. 11/30/09 Dr Bonesetter, MD. Karen Smith, PA-C. Orthopedics. Doing well.
Improves on weekly basis. Gets discomfort on medial thigh with flexion extreme.
Doing well. Remain off work. Follow up one month Dr. Bonesetter.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
19. 10/27/09 Dr Bonesetter, MD. Orthopedics. Started walking a little more. Left hip
excellent range of motion. Soreness normal four weeks out from surgery.
Restrictions for lifting and squatting.
20. 10/27/09 Dr. Rita Nelson. Follow up Dr. Bonesetter better. Pain improved.
Records Dr. Bonesetter requested.
21. 10/5/09 Dr Bonesetter, MD. Orthopedics. Fist postoperative evaluation. No pain.
Ambulating without device. Excellent range of motion left hip. Off work. Doing
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well. “I am amazed at how well the patient is doing only 10 days out.” Required
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extensive labral debridement, could cause future problems.
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22. 8/23/09 Dr Bonesetter, MD. Orthopedics. Operative report. Left hip debridement
of labrum, debridement of synovium, chondroplasty of acetabulum and acetabular
rim trimming.
23. 9/11/09 Dr. Rita Nelson. Phone call. Not taking pain medication tolerating full
duty.
24. 8/19/09 Dr. Rita Nelson. Phone call to patient. Surgery planned. Tolerating full
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duty.
25. 8/17/09 Dr Bonesetter, MD. Orthopedics. Consult format report. Left hip injury
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seven months ago. X-ray ossification acetabular labrum. MRI reveals anterior
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labral tear. Early degenerative changes within the hip. Good relief from intraarticular injection, and good surgical candidate (arthroscopy, labral repair vs.
debridement with possible osteo chondroplasty. Patient agrees to proceed. Cc Dr.
Bonefixer and Dr. ta Nelson.
26. 7/30/09 Dr. Rita Nelson. Phone call. Appt with Dr. Bonesetter 8/17/09. Pain
slightly better overall.
27. 7/10/09 Dr. Bonassi. Phone call. Authorization for surgical evaluation Dr.
Bonesetter requested.
28. 6/19/09 Dr. Rita Nelson. Phone call regarding surgical consultation.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
29. 6/15/09 Dr. Bonefixer MD. Orthopedics. Consult left hip pain. History reviewed.
Exam full motion both hips. MRI arthrogram labrum tear. Plan referred to Dr.
Bonesetter for arthroscopic hip surgery.
30. 5/29/09 Dr. Rita Nelson. MRI report reviewed. Orthopedic consult request Dr.
Degenhardt.
31. 5/21/09 Dr. Radman: MRI left hip: anterior labral tear (with gadolinium).
32. 5/21/09 Dr. Consult. Occupational Medicine Clinic. Fluoroscopy injection for
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MRI.
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33. 5/1/09 Dr. Rita Nelson. Seen for strain left hip. MRI hip ordered.
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34. 4/10/09 Dr. Rita Nelson. Left hip pain visit. Therapy ordered. Full duty.
35. 3/23/09 Dr. Ty. Left Hip arthrogram corticosteroid injection 80mg Kenalog.
36. 2/19/09 Physical Therapy Note.
37. 2/10/09 Dr. Rita Nelson. X-ray hip review note.
38. 2/10/09 Dr. Rita Nelson. First report of injury. Full hip prom. Diagnosis strain.
Consult physical therapy. Referenced is prior care with Drs. Bonassi and Zoe;
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stating left groin strain followed by Dr. Bonassi Occ Med in 2007 and Dr. Zoe
Occ Med 2007-2009. Unclear if injury is new or prior treated groin injury. (These
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other doctor reports are not available for review).
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39. 2/10/09 Dr. Radman, MD. X-ray Left Hip: No significant abnormalities. Mild
enthesopathy at iliac crests and tuberosties bilateral.
Section 4. Identifying Employment Background Information
Job Title: Mechanic II
Employer: City of Anywhere, USA
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Length of Employment: Nine years
Current Work Status: Full and unrestricted but he states careful with heavy lifting.
Hand Dominance: (x)Right ()Left
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Section 5. Injured Body Location(s) & Mechanism of Injury
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Injured Body Location:
1) Left hip to include: left inner groin, left buttock
Mechanism of Injury:
Mr. Doe is a now 51 year old male employed as a Mechanic (II) by Anytown, USA on
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1/21/09 in a pain free, fully functional state, when he was installing a heavy pump. In the
process of doing so he felt and immediate “pop” and “snap” in his left groin/hip with the
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onset of pain. Pain was also noted to be present in the left buttock and left groin (at the
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insertion of the hip adductors). He went on to get therapy, a joint injection, medications
and finally MRI imaging (with gadolinium) that showed torn cartilage (labrum tear) . He
was referred to Dr. Bonesetter, Orthopedics, who performed a left hip surgery
(arthroscopy) on 8/23/09 (to include left hip debridement of labrum, debridement of
synovium, chondroplasty of acetabulum and acetabular rim trimming).
Following surgery, he did notice improvement in his deep left hip pain, however, still had
pain in the left groin and left buttock (near the ischium). He has since been returned to
full duty, and made permanent and stationary by Dr. Bonesetter. His pain, however,
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
continues in the left groin and buttock. He was referred today for evaluation at the
direction of Claims Administrator Jane Doe.
Section 6. Prior Treatment Summary & Relevant Information
Medication Trials to Date: Ibuprofen
Imaging to Date:
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Current Splints or Supportive Devices: None
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Physical Therapy Visits to Date: “about 18” estimated by employee.
1. 5/21/09 Dr. Radman. MRI left hip: anterior labral tear (with gadolinium).
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2. 2/10/09 Dr. Radman, MD. X-ray Left Hip: No significant abnormalities. Mild
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enthesopathy at iliac crests and tuberosties bilateral.
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Surgery for this Injury:
1. 8/23/09 Dr. Bonesetter. Left hip arthroscopy and debridement of labrum and
synovium, chondroplasty acetabulum and acetabular rim trimming.
Additional consultations/providers for this Injury:
1. 2/10/09-2/23/10 Prior care Dr. Rita Nelson, Occupational Medicine.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
2. 6/15/09 Dr. BonefixerMD. Orthopedics.
3. 3/23/10 Dr. Sharon Ruiz, D.C.
Significant Past Medical History:
Mr. Doe states that in 2007 he had a Workers’ Compensation claim treated with Dr. Rita
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Nelson that included his left thigh (adductor) and knee. There were no permanent
work.
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restrictions, and he got “$1100 bucks”. Future care was provided and he returned to usual
The note from Dr. Rita Nelson, mentions the employee was followed by Dr. Bonassi Occ
Med in 2007 and Dr. Zoe Occ Med 2007-2009 for left groin strain. These reports are not
available for review.
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Review of Systems: “An inventory of body systems obtained through a series of
questions seeking to identify signs and/or symptoms that the patient may be experiencing
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or has experienced”.
Constitutional, eyes, ENT, throat, cardiovascular, respiratory, gastrointestinal,
genitourinary, musculoskeletal, skin/integumentary, neurological, psychiatric, endocrine,
hematological/lymphatic, allergic/immunologic. Non Contributory.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Section 7. Current Symptoms & Complaints
History of Present Illness (Eight Elements)
Body Location: Left hip (lateral thigh ¾ length of muscle belly), medial thigh ( ½ of
proximal adductor region) and left buttock (ischium and sciatic notch region).
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Pain Quality: Ache and sore
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Pain Intensity/Severity: 3/10
Pain Frequency/Duration: Functionally related only as noted above.
Modifying Factors/Improves Pain/Timing/Context: Rest.
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Modifying Factors/Worsens Pain/Timing/Context: Pain left buttock (ischium) with even
weight distribution when he sits. He avoids sitting on the left side due to pain. He has
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pain in the groin and thigh if he takes wide stride steps or needs to spread the legs to
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mount a large vehicle etc. and step up. No pain with walking, squatting or lying down.
There is no positional pain of the groin.
Current Medications for Condition: Ibuprofen 800mg 1-4 times per week. No medication
side effects.
Comments/Associated signs and symptoms: There is no hip region pain with internal or
external rotation. There is no additional radiating symptoms beyond above. There are no
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
bowel or bladder problems. He has not been checked for a hernia to his knowledge. He
has had no groin bulge or masses.
Section 8. Activity of Daily Living Affected by Injury
Adopted from Table 1-2 Activities of Daily Living Commonly Measured in Activities of
Living (ADL) and Instrumental Activities of Daily Living (IADL) Scales, page 4,
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Guides to the Evaluation of Permanent Impairment, Fifth Edition, American Medical
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Association, AMA Press:
1)Self Care/Personal Hygiene: No Limitations
2)Communication: No Limitations
3)Physical Activity: No Limitations. Notes pain with a wide stride or wide step up (on
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vehicles etc.)
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4)Sensory Function: No Limitations
5)Non Specialized Hand Function: No Limitations. Lifting more than 80 pounds may
flare pain or forceful upward squatting (lifting under a vehicle during a repair).
6)Travel: No Limitations
7)Sleep: No Limitations. He sleeps poorly up to six or seven hours per night, but not sure
this is due to hip or insomnia in general.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
8)Sexual Functioning: No Limitations
Section 9. General Past Medical, Family & Social History
Past Medical History:
1. Seasonal allergies x 12 years. No asthma.
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Past Surgical History:
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2. Health maintenance exam six months ago with blood work pending.
1. Left hip surgery as noted above.
2. Left knee surgery 2007
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Current Medications:
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1. Ibuprofen 800mg 1-4 times per week.
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Allergies: None known to medications.
Family History:
Health/status/cause of death for parents, siblings (identify diseases or hereditary
conditions)
Parents: Father deceased from lung cancer age 71 years old. He also had emphysema and
was on medication. Mother is alive at 79 years old..
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Siblings: Unknown.
Children: Two: Daughter 15 years old healthy. Daughter 7 years old has asthma.
Social History:
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Marital status/ living arrangements: Married with two children.
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Current Employment Status: Full duty.
Occupation history: Equipment mechanic entire life. He was a supervisor at Anytown
Automotive in the past as well.
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Use of drugs, alcohol, tobacco: No drugs or tobacco. Alcohol 0-2 per month.
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Level of education: High School Degree. One year college.
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Other relevant social factors:
Military Service: None
Second Jobs/Self Employment: None
Hobbies: Soccer coaching. He avoids soccer now because of the running involved and his
hip.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Section 10. Physical Examination Findings
Physical Exam:
Vital Signs: BP: 122/83 HR: 70 RR: 16 Ht: 69” Wt: 202 # BMI: 29.8 kg/m2
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Psychiatric: Alert and Oriented x 3
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General Appearance: No Acute Distress, obese.
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Ideal Body Weight (BMI 25) = 169#. The employee is 33# over ideal body weight.
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Head: Clear to include oropharynx, conjunctiva, external nares and ears
Neck: Supple, without adenopathy
Chest: Clear to Auscultation all fields
Cardiac: Regular, No Murmur, no extremity cyanosis or edema
Abdomen: Soft, Normal Bowel Sounds.
Ortho:
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Leg Measurement:
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Skin: No rash, tightening, ecchymosis or erythema in areas examined.
Mid Thigh: Right(57)cm Left(57)cm
Knee: Right(39)cm Left(39)cm
Calf (10 cm Below Tibial Tubercle) Right(38)cm Left(37)cm
Ankle: Right(23)cm Left(23)cm
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Lumbar Spine:
Inspect: Normal lordotic curve. No Scars or Swelling. No asymmetric motion.
Palpation: Non-Tender, no palpable spasm, or guarding.
Lumbar Ranges of Motion Table A-2 page 597: Motion is reported right over left side in
Degrees (D). AMA Estimated Normal: Flexion (60D), Extension (25D), Lateral Bend
(Right and Left) (25D).
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Measurements are obtained with bubble inclinometer (two location method).
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Lumbar Flexion: (110-82=28)
Lumbar Extension: (25-0=25)
Lumbar Lateral Bend: (25-10=15/25-10=15)
Neurovascular: Intact L4-S1 Motor, Light Touch, Reflexes
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Genital Male:
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Straight Leg Raise Sitting: Negative
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Appearance: Normal genitals
Testicles: No Swelling. Non Tender Without masses
Inguinal Canal Inversion with Valsalva/Cough: Positive left side with dynamic sliding
inguinal hernia. Right side negative.
Hip: (x)Right(x)Left
Inspect: No Swelling or Deformity. No Erythema. There are two, one centimeter healed
trochar scars left anterior hip and iliac crest anterior. These are Hyperpigmented.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Palpation: Tender left sciatic notch, and diffuse “soreness” abductor proximal ½ distance
down leg, and ¾ distance down adductors. There is tenderness at the pubic insertion and
femoral triangle.
Hip Ranges of Motion Table A-3 page 598:
Motion is measured with goniometer, and is reported right over left side in Degrees (D).
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(20D) External Rotation (50D), Internal Rotation (40D).
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AMA Estimated Normal: Flexion (100D), Extension (30D), Abduction (40D), Adduction
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Flexion: (135 133 135/115 113 115) Valid Right and Left
Extension: (40 40 41/42 42 43) Valid Right and Left
Abduction: (55 53 55/85 83 83) Valid Right and Left
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Adduction: (35 35 32/30 31 31) Valid Right and Left
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External Rotation: (60 63 63/75 73 73) Valid Right and Left
Internal Rotation: (73 73 75/55 56 56) Valid Right and Left
Gait: Normal arch and medial longitudinal attitude. Gait observed from heel strike to toeoff. Stance is stable. Toe-off with normal propulsive phase. Non Antalgic.
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Section 11. Summary Claim Diagnoses
Assessment:
1. Left hip strain 843.9 with labrum tear by MRI gadolinium now status post left hip
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arthroscopy and debridement of labrum and synovium, chondroplasty acetabulum and
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acetabular rim trimming on 8/23/09 by Dr. Bonesetter. Industrially related.
2. Left inguinal hernia 550.90 Unilateral or unspecified inguinal hernia without
obstruction or gangrene. See discussion below for comment.
Section 12. Summary Discussion and Opinion
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Summary Discussion:
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Mr. Doe is a now 51 year old male employed as a Mechanic (II) by Anytown, USA on
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1/21/09 in a pain free fully functional state when he was installing a heavy hydraulic
pump. In the process of doing so he felt and immediate “pop” and “snap” in his left pain
with the onset of pain. Pain was also noted to be present in the left buttock and left groin
(at the insertion of the hip adductors). He went on to get therapy, a joint injection,
medications and finally MRI imaging (with gadolinium) that showed torn cartilage
(labrum tear) . He was referred to Dr. Bonesetter, Orthopedics, who performed a left hip
surgery (arthroscopy) on 8/23/09 (to include left hip debridement of labrum, debridement
of synovium, chondroplasty of acetabulum and acetabular rim trimming).
19
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Following surgery, he did notice improvement in his deep left hip pain, however, still had
significant pain in the left groin and left buttock (near the ischium). He has since been
returned to full duty, and made permanent and stationary by Dr. Bonesetter. His pain,
however, continues in the left groin and buttock. There is no indication for additional
pain rating in Chapter 18, Pain. There is no indication for rating by analogy, as the
conventional rating methods have offered adequate assessment of the employee’s medical
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hip condition and captures his level of suffering.
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Mr. Doe’s left, post surgical hip, is to be considered at maximal medical improvement
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(MMI), with excellent range of motion, and no joint pain with motion on exam. The
impairment rating process will be applied for this portion of his claim below. The
employee’s left hip has reached a point of maximal medical improvement as that term is
defined by page 601 of the AMA Guides 5th Edition. I do not believe there will be
additional meaningful improvement in the medical condition(s) described in the next 12
months. I find the employee’s left hip at maximum medical improvement as of the date
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8/10/10 submitted by Dr. Bonesetter. This is also the date on which the employee is
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found "permanent and stationary".
hernia.
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Exam today also reveals Mr. Doe to have a sliding (dynamic), but palpable, left inguinal
Two issues are at play here.
The first issue is whether or not the proposed mechanism of lifting that injured the left
hip, could have produced the hernia found today with medical probability. In my opinion,
the answer is “yes”, the mechanism is consistent with the medical findings. It would also
be helpful to forward me the prior 2007 Occupational Medicine notes for review to
20
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
understand more about how his groin was implicated, if at all in that injury, and review
for a documented hernia exam at that point in time. Prior DOT exams if available would
be helpful in this respect as well.
The second issue is more complex, and that is how much the left inguinal hernia is
contributing to his ongoing groin, adductor, abductor, and buttock pain. My opinion is
that it may be contributing to some, but not all, of the reported ongoing pain location. The
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hernia, may very well be contributing to pain in the high medial adductor insertion region
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and femoral triangle findings. Of course, there will no way to tell until the hernia is
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assessed for repair, fixed, and appropriate six to 12 weeks of healing has ensued. That
being said, the reader must understand that Mr. Doe could very well have ongoing pain in
the abductors and will likely have his ischium pain in the left buttock region unchanged
despite hernia repair.
In efforts of expediting this claim and offering the employee every opportunity of
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consultation and improvement, I am requesting that his left hernia be verified, and
causation be re-visited and opined by a general surgeon. For this purpose I recommend
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that Dr. Cruss, MD and General Surgeon Tel. (123) 456-789, address: 123 Montgomery
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Drive Ste A, Anytown, CA 91234, be authorized for a ML 102 evaluation for the
purposes of introducing the left inguinal hernia into the claim. I did place a call to
Adjuster Jane Doe at the conclusion of the exam today, and she has since returned an
email to me authorizing Dr. Cruss for this purpose. If appropriate, and agreed upon by all
parties beyond the function of initial consultation, Dr. Cruss can surrender his ML
evaluator status and become the employee’s designated treating physician for the
purposes of the hernia repair and recovery to MMI status.
21
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
If my opinion on left hernia is supported by Dr. Cruss, General Surgeon, I would ask that
he be returned to me for a re-evaluation at the time he is released from the surgeon’s care.
Section 13. Decision Making and Impairment Calculations
High Level Medical Decision Making; to include: The number of diagnoses, the amount
and/or complexity of data (medical records, diagnostic tests, and/or other information that
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must be obtained, reviewed and analyzed), the risk of significant complications,
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morbidity, and/or mortality, as well as comorbidities, associated with the patient’s
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presenting problem(s), the diagnostic procedures(s) and/or the possible management
options, and/or additional referral for surgical or invasive diagnostic procedures.
Impairment Calculations/Rating:
Source: Guides to the Evaluation of Permanent Impairment, Fifth Edition, American
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Medical Association, AMA Press.
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Rating Chapter: Hip Motion /17 Lower Extremities
Comments: AMA Guides 5th Edition: Page 453 "If a contra-lateral "normal"
joint has less than average mobility, the impairment value(s)
corresponding to the uninvolved joint can serve as a baseline and are
subtracted from the calculated impairment for the involved joint".
Page 20: "Two measurements made by the same examiner using the Guides that involve
an individual or an individual's functions would be consistent if they fall within 10% of
each other."
22
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Rating Table/Figure:
Applied (x) Yes / () No : Range of Motion Loss: Tables 17-9 page 537
Calculations:
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External Rotation: 0%, Abduction: 0%, Adduction: 0%.
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Non Injured Right Side: Flexion: 0% (WPI), Extension: 0%, Internal Rotation: 0%,
Injured Left Side: Flexion: 0% (WPI), Extension: 0%, Internal Rotation: 0%, External
Rotation: 0%, Abduction: 0%, Adduction: 0%.
Injured Side minus Non Injured Side:
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Flexion: (0) – (0) = (0)% WPI
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Extension: (0) – (0) = (0)% WPI
Abduction: (0) – (0) = (0)% WPI
Adduction: (0) – (0) = (0)% WPI
External Rotation: (0) – (0) = (0)% WPI
Internal Rotation: (0) – (0) = (0)% WPI
23
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Final Adjusted Total Impairment for Injured Side Hip ROM: (0)% WPI
Whole Person Impairment Rating= 0 %
Comment: The employee’s procedure does not meet criteria for DRE rating on additional
hip conditions Table 17-33 page 546 Impairment Estimates for Certain Lower Extremity
Impairments. There are no imaging reports to support rating on Table 17-31 page 544
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Arthritis Impairments Based on Roentgeongraphically Determined Cartilage Intervals
Rating Chapter: 18 Pain
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**
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(standing films ideal).
Rating Table/Figure: Figure 18-1 Algorithm for Rating Pain-Related Impairment in
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Conditions Associated with Conventionally Ratable Impairment page 574.
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Calculations: If pain-related impairment appears to increase the burden of the
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individual’s condition slightly, the examiner can increase the percentage found in step 1
(Use of the conventional rating system) by up to 3%. No formal assessment of painrelated impairment is required.
Whole Person Impairment Rating = 0% WPI under Chapter 18
Comments: There is no basis for add on pain rating if there is no underlying impairment
rating regarding the left hip.
24
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Section 14. Final Claim Summary and WPI
Final Claim Summary:
Location #1: Left Hip 0%WPI
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Location #2: Left Inguinal Hernia Pending Surgical Consultation (see discussion
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above).
Final Left Hip Claim WPI= 0%
Section 15. Permanent Functional Restrictions
Permanent Functional Restrictions: Left Hip: None Indicated. For Left Inguinal Hernia:
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No heavy lifting > 15 pounds.
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Section 16. Causation
Causation: Based on my review of the available diagnostic tests/x-ray, chart review,
history taken from the employee, and the results of the physical examination, it is my
opinion, to a reasonable degree of medical certainty that this injury (left hip and left
inguinal hernia) was caused by the described industrial injury.
25
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Section 17. Future Medical Care
Future Medical Care: Left Hip
Future Medical Care for left hip pain flares related to this claim:
-4 visits per year for non narcotic/non habit forming pain medications
-6 visits per year of therapy for pain flares
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-Access to orthopedic provider for additional imaging, cortisone injections and surgery
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consideration should conservative treatment fail, however, no surgery is anticipated in the
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near future or next one year.
Section 18. Pain Assessment
Pain assessment: As Adopted by the DWC Form PR-4 (Rev. 06-05) STATE OF
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CALIFORNIA Division of Workers’ Compensation
If the burden of the worker’s condition has been increased by pain-related impairment in
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excess of the pain component already incorporated in the WPI rating under Chapters 3-17
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of the AMA Guides, 5th Edition, specify the additional whole person impairment rating
(0% up to 3% WPI) attributable to such pain. For excess pain involving multiple
impairments, attribute the pain in whole number increments to the appropriate
impairments. The sum of all pain impairment ratings may not exceed 3% for a single
injury.
Additional Pain Award for this Claim: None indicated for left hip.
26
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Section 18. Apportionment
Apportionment: As Adopted by the DWC Form PR-4 (Rev. 06-05) STATE OF
CALIFORNIA Division of Workers’ Compensation
Effective April 19, 2004, apportionment of permanent disability shall be based on
causation. Furthermore, any physician who prepares a report addressing permanent
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disability due to a claimed industrial injury is required to address the issue of causation
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of the permanent disability, and in order for a permanent disability report to be complete,
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the report must include an apportionment determination. This determination shall be
made pursuant to Labor Code Sections 4663 and 4664 set forth below:
Labor Code section 4663. Apportionment of permanent disability; Causation as basis;
Physician's report; Apportionment determination; Disclosure by employee
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(a) Apportionment of permanent disability shall be based on causation.
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(b) Any physician who prepares a report addressing the issue of permanent disability due
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to a claimed industrial injury shall in that report address the issue of causation of the
permanent disability.
(c) In order for a physician's report to be considered complete on the issue of permanent
disability, it must include an apportionment determination. A physician shall make an
apportionment determination by finding what approximate percentage of the permanent
disability was caused by the direct result of injury arising out of and occurring in the
course of employment and what approximate percentage of the permanent disability was
caused by other factors both before and subsequent to the industrial injury, including
27
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
prior industrial injuries. If the physician is unable to include an apportionment
determination in his or her report, the physician shall state the specific reasons why the
physician could not make a determination of the effect of that prior condition on the
permanent disability arising from the injury. The physician shall then consult with other
physicians or refer the employee to another physician from whom the employee is
authorized to seek treatment or evaluation in accordance with this division in order to
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make the final determination.
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permanent disabilities or physical impairments.
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(d) An employee who claims an industrial injury shall, upon request, disclose all previous
Labor Code section 4664. Liability of employer for percentage of permanent disability
directly caused by injury; Conclusive presumption from prior award of permanent
disability; Accumulation of permanent disability awards
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(a) The employer shall only be liable for the percentage of permanent disability directly
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caused by the injury arising out of and occurring in the course of employment.
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(b) If the applicant has received a prior award of permanent disability, it shall be
conclusively presumed that the prior permanent disability exists at the time of any
subsequent industrial injury. This presumption is a presumption affecting the burden of
proof.
(c)(1) The accumulation of all permanent disability awards issued with respect to any one
region of the body in favor of one individual employee shall not exceed 100 percent over
the employee's lifetime unless the employee's injury or illness is conclusively presumed
28
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
to be total in character pursuant to Section 4662. As used in this section, the regions of
the body are the following:
A) Hearing.
(B) Vision.
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(C) Mental and behavioral disorders.
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(D) The spine.
(E) The upper extremities, including the shoulders.
(F) The lower extremities, including the hip joints.
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(G) The head, face, cardiovascular system, respiratory system, and all other systems or
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regions of the body not listed in subparagraphs (A) to (F), inclusive.
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(2) Nothing in this section shall be construed to permit the permanent disability rating for
each individual injury sustained by an employee arising from the same industrial
accident, when added together, from exceeding 100 percent.
Apportionment for this claim Left Hip: SB899 and Almaraz/Guzman I/II are considered.
None known. If additional comment on apportionment is requested, a supplemental
report will be issued upon receipt of supporting medical documentation. Please send any
29
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
requested documentation with a pre-approval cover letter pre-authorizing a ML 101
supplemental report.
Section 19. Displaced Worker Benefits & Vocational Rehabilitation
Vocational Rehabilitation: Left Hip: The employee is not considered eligible for
displaced worker benefits. The applicant may resume usual and customary work with
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Section 20. Affidavit and Examiner Signature
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regards to his left hip.
Affidavit:
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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, as to
information that I have indicated I received from others. As to that 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.
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I further declare under penalty of perjury that I personally performed the evaluation of the
patient or, in the case of a supplemental report, I personally performed the cognitive
services necessary to produce the report on said date of this visit and that, except as
otherwise stated herein, the evaluation was performed and the time spent performing the
evaluation was in compliance with the guidelines, if any established by the Industrial
Medical Council or the administrative director pursuant to paragraph (5) of subdivision
(j) of Section 139.2 or Section 5307.6 of the California Labor Code.
I further declare under penalty of perjury that I have not violated the provisions of
California Labor Code Section 193.3 with regard to the evaluation of this patient or the
preparation of this report.
I further declare under penalty of perjury that the name and qualifications of each person
who performed any services in connection with the report, including diagnostic studies,
other than clerical preparation, are as follows:
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Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com
Impairment
Rating
Specialists
Dr. John W. Alchemy, MD
I Verify under penalty of perjury that the total time I spend on the following activities is
true and correct:
a) Reviewing the records=(127) minutes
b) Face to face time with the patient: (70) minutes
c) Preparing the report=(187) minutes
John W. Alchemy, MD
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Date of Report: Signed this__17__day of __Feb__2011, at Sonoma County.
Impairment Rating Specialists Unlimited
www.pr4report.com
email: jamd@pr4report.com
Diplomate of the American Board of Family Practice
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Qualified Medical Examiner State of California
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American Academy of Medical Review Officers
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American Board of Independent Medical Examiners Certificate 06-00053
ACOEM Compliant
California Medical Lic. # A055085
31
Dr John Alchemy, MD
Date of Evaluation:2/17/11
Employee: Doe, John
2360 Mendocino Avenue, Suite A2 • Santa Rosa, CA 95403 • p 707.483.4346 • f 206.338.3005 • info@pr4report.com