Newsletter Index

Worker's Compensation Sample  

This is a sample in which I was asked to refute the opposing expert physician’s arguments.  I did so. My attorney told me that as soon as the opposition received my report, they contacted him and wanted to settle the case.  Dates and some of the information has been changed, so
that the report could be used as a sample work.
 

Attorney John Doe
1670 Lake Park Circle
Morristown, TN  37814-1465 

Dear Attorney Doe, 

I have been asked in the course of my practice as a nationally certified legal nurse consultant to review the medical records of ________________, now deceased.  The medical records that I reviewed have included:  The hire-in medical examination report by Dr. ____________;  the outpatient surgery performed by ___________ on 09/02/2001, along with Dr. ___________’s History and Physical, and the surgical pathology of Dr. ______________; the _______Hospital  records of 10/09/02  to 10/21/02.  I have also reviewed the Affidavits of Dr.___________, ___________ and ____________.  Personally, I met and talked with _________’s widow, ______________. 

(Dr. S. was the opposing physician expert for the worker's compensation insurance company)

The medical records do not support Dr. S.’s assertion that ___________was obese, and it is not a medical probability that he was overweight.  He is documented to have been 5’11” with a known weight of 225 lbs. on the date of his pre-hire physical.  ____________, spouse of over twenty (20) years, upon personal interview stated that her husband was a high school football athlete and that he maintained a constant muscular, stocky body build throughout their marriage.  Medical records confirm a consistent weight of 225 lbs. with active physical lifestyle. 

Dr. ____________’s records of 11/08/1991 show height and weight as 5’11” tall and 225 lbs.  According to wife, ____________, her husband maintained a consistent weight for well over twenty (20) years.  According to the records in the Patient Assessment of 09/02/01, _________continued to be 5’11” tall and 225 lbs, confirming information from wife. 

According to Dr. S._______, "findings were consistent with and indicative of long-standing idiopathic hypertension”.  Dr. S. concluded that _________________had “hypertension associated with preexisting renal disease and premature atherosclerosis”.  He stated that the renal disease was of “probable chronic nature”. 

According to the National Institutes of Health’s Dictionary, “idiopathic” is defined as: arising spontaneously from an obscure or unknown cause.  Dr. S.’s statements of “long-standing” and “probable chronic nature” are not consistent with the National Institute of Health’s definition of “spontaneous”.  “Idiopathic” as per the NIH means “obscure or unknown cause” and also conflicts with Dr. S.’s statement that the preexisting renal disease and premature atherosclerosis were the cause of hypertension. 

Further detailed review of the medical record is revealing with regard to hypertension associated with surgery by Dr. N. in 2001.  Blood pressure noted on Outpatient Record of 09/02/2001 was 202/140.  Dr. N. addressed the issue in the
H & P and stated that he felt the hypertension was due to anxiety.  According to the Perioperative Care Plan from ____________Hospital, anxiety is listed as #1 and #2 in the "Diagnoses" labels”.   Anxiety related to going to an unknown environment, fear of findings (in patient’s case—wife stated that he was afraid of possible cancer and if the cancer had metastasized) , pain or discomfort, procedure of surgery.”  The nurse noted “yes” to these statements.  In #14, the nurse checked affirmative to “potential disturbance of self concept: impaired self-esteem related to dependant state and altered body image related to illness, trauma”.  There was a high probability that the basal call lesion could be cancerous. These noted and verified environmental and health issues related directly to elevated blood pressure readings. 

According to wife_________, the patient had never been to the hospital before and had never had surgery.  He was very anxious about this procedure.  Wife also stated that _______took Tylenol Sinus for allergies and sinus drainage.  This was confirmed and noted in the Surgery History and Physical for 09/02/2001.  Tylenol Sinus medication increases blood pressure as per the Physician’s Desk Reference and federally mandated warnings included in boxes of sinus and allergy medications. 

On discharge after the procedure, patient was able to go home.  B.P. was decreased at 160/100.  Although above normal readings, it is noteworthy that blood pressure was significantly lower as the stress reduced after surgery and findings. 

According to a study published by the Journal of American Medical Association (JAMA), 21 % of 292 participants in a study done by the AMA, had “White Coat Syndrome”.  “White Coat Syndrome” is defined as unusually high blood pressure readings in a doctor’s office, outpatient/hospital setting and which return to normal upon returning to the normal home or to a familiar environment. 

“White Coat Syndrome” as described by The Blood Pressure Association has the same definition as above.  Blood pressure goes up and down throughout the day and night.  This is normal.  When a person is excited or in pain, as having pain from a deep-layered basal skin lesion and being excited due to never having surgery or never having been in a hospital; the blood pressure rises.  White coat hypertension and the white coat effect are caused by anxiety, when the body stimulates the “fight or flight” response.  Many people are aware that they feel nervous or anxious, but many others may think that they are relaxed, when in fact, they are not.  The syndrome can affect anyone, young or old, male or female, according to The Blood Pressure Association. 

As noted by wife, _________, patient had never shown signs of hypertension such as, headaches, blurred vision, nausea, vomiting, unusual tiredness, confusion, blood in urine, nosebleed, irregular heart beat, chest pain, ear noise or buzzing, shortness of breath or unusual sweating.  Those are some of the symptoms listed by the American Medical Association. 

The hypertensive pre-surgery blood pressure readings are entirely consistent with stressors relating to the surgery and no conclusions to a reasonable degree of medical certainty are warranted. 

According to the affidavit of fellow worker, ___________ patient seemed highly upset and stressed because of __________________________________.  He stated he had been “chewed out” by the boss because he wasn’t keeping the new quota requirements, and_______________.  Patient’s physical appearance was notable with regard to the fact that his eyes were red and somewhat glassy.  His eyes were red, swollen and bloodshot and his face had a reddish color.  His conversation focused upon the new quota requirements, how unfair he felt that the requirements were and the fact that _________________________. 

The Comprehensive Textbook of Psychiatry/VI, edited by Harold Kaplan, MD, Professor Psychiatry of New York University School of Medicine, and Benjamin J. Sadock, M.D., Professor and Vice Chairman of the Department of Psychiatry of New York University School of Medicine, states that; “As a transient, disagreeable emotional state, anxiety may be adaptive, signaling anticipated or impending threat.  In contrast to fear, the emotional state that exists when a source of threat is precise and well-known, anxiety occurs when the threat is not well-defined.  Anxiety is characterized by intense negative affect, associated with an undefined threat to one’s physical or psychological self. 

“During adult life, anxiety often centers on issues of mastery and accomplishment in both personal life and work life, Performance anxiety is a specific type of pathological anxiety in which anxiety escalates to episodes of panic when public performance is required.” 

“The classic precipitants of anxiety include helplessness, the threat of impending injury, separation from a secure environment, social disapproval and decreased self-esteem.  Most of these factors are present when a person becomes ill.”

On the H & P for _____________Hospital on 10/09/2004, the physician dictated as an Impression, “Diabetes Mellitus”.  Sliding scale insulin was implemented.  Blood sugar on admission was 160.  Normal values vary from hospital to hospital, but from my experience, a normal glucose is around 80-120.  It is unknown, as I haven’t had access to the EMS records during transfer to ________Hospital, but a high probability from my experience as an Emergency Room Supervisor and having ridden in many ambulances with patients throughout the years, is that IV’s containing Dextrose, such as D5LR or D5W were initiated and continued to arrival at the receiving hospital.  It is a high probability, in my experience, that the Dextrose in the IV would account for the 160 glucose reading. 

On 10/10/04,  in the physician’s progress notes, the Hgb AIC on 10/10/04 was 5.3.  According to the Cecil Textbook of Medicine 22^nd Edition of 2004 and edited by Lee Goldman, M.D., Associate Dean of the University of California; the normal Hgb AIC is an index of control for the past 6 to 12 weeks prior to the lab drawing, and the normal is <6.  Therefore the patient’s lab was normal at 5.3 and shows a high probability that he was NOT diabetic. 

Wife_____________, stated that her husband had never voiced c/o of symptoms of diabetes mellitus, such as unexplained weight loss, increased appetite, drinking abnormal amounts of fluids, excessive urination, excessive fatigue, blurred vision or impotence. 

Decadron is a synthetic steroid given to decrease inflammation of the brain and is given in head injuries, head trauma, meningitis, strokes, etc.  Decadron also increases blood sugar readings according the Physician’s Desk Reference and Decadron’s package insert.  Decadron was started on 10/10/04, according to the Medication Administration Records (MAR) at_____________Hospital.

Dr. S.’s affidavit states that “Preexisting renal disease is evidenced by the initial renal function tests on admission to the ____________Hospital, which tests included BUN and creatinine, urinalysis, and urinary microalbumine, all of which were normal.  Dr. S. indicated renal dysfunction of “probable chronic nature”. 

BUN on admission was in normal range of 17.  Normal range is 7-18.  Creatinine was 1.5 and essentially normal.  Normal range is 0.7-1.3.  Urine specimen was normal except for increased protein of over 300 mg/D+F and the normal range is negative.  The next specimen on 10/16/04 was 30 mg/D+F.  There was a small amount of blood on admission and a moderate amount of blood on the next specimen of 10/16/04.  No renal scans or other renal test were recorded. 

In renal insufficiency, according to the National Kidney Foundation; BUN levels are increased, creatinine is increased and potassium levels in the blood are increased.  BUN and creatinine did increase only after admission.  ______________’s BUN, creatinine and potassium levels were normal on admission.  Potassium level was 3.9 with normal being 3.5 to 5.1. 

According to the most recent AMA Guides to the Evaluation of Permanent Impairment, “the serum creatinine level reflects overall renal function”.    _______’s serum creatinine was essentially normal.   "The creatinine clearance is the most accurate reflection of renal function, but this test was not done". 

Symptoms of kidney disease per The National Kidney Foundation, of which surviving spouse, _______, stated _________had never had are: unintentional weight loss, nausea and/or vomiting, a general ill feeling, unusual fatigue, headaches, frequent hiccups, generalized itching, increased or decreased urine output, increased urination at night, easily bruising or bleeding, blood in stools or urine, decreased alertness, puffiness around eyes or face, ankles, wrists, muscle twitching or muscle cramps, seizures, decreased sensation in hands, feet or other areas, excessive thirst, abnormally dark or light skin, paleness nail abnormalities, unusual breath odor, and loss of appetite. 

Dr. S. concluded that: “The CT scan performed during the hospitalization revealed premature atherosclerosis from a finding of calcification of the vertebral arteries.  All of these findings are consistent with and indicative of long-standing, idiopathic hypertension”  He relied upon a CT scan, which had been done 10/10/04. 

According to the American Academy of Neurology, the MRI is the procedure of choice in brain and neurological disorders.  90% of all MRI’s are for brain or spinal disorders.  CT scans are done preferably in the first 48 hours after brain insult.  This was done. 

The MRI is the procedure of choice in brain neurologic disorders, as per The American Stoke Association.  The MRI did NOT show premature atherosclerosis or any other atherosclerosis. 

The MRA test is a very specific test like the MRI.  According to the 22^nd Edition of Cecil Textbook of Medicine edited by Lee Goldman, M.D., Associate Dean for Clinical Affairs for the Department of Medicine at the University of California, and Dennis Ausiello, M.D., Professor Clinical Medicine at Harvard Medical School in Boston, Massachusetts: MRA is the BEST noninvasive technique for evaluating extracranial and intracranial vasculature.  MRA may be performed with or without contrast to evaluate long segments including the origins of the great vessels of the neck.  A weakness of MRA is that is may overestimate the degree of vascular stenosis.  Patient’s MRA revealed, “there was NO hemodynamically significant stenosis”. 

The medical record does not support a conclusive finding of premature atherosclerosis and calcification of vertebral arteries when the more accurate and detailed MRI and MRA results are considered. 

My review of the medical record and the affidavits referenced supports the opinion that the medical history for _________________is somewhat meager.   _____________was known to be seen by physicians on just three (3) occasions during his adult lifetime.  He had a pre-hire physical by Dr. ______________on 11/08/92.   He had surgery by Dr. _______________on 09/02/01.   His only other known involvement with the medical community was his last illness.  He was only 42 years old when he expired, had no previous complaints, and was symptom free prior incident. 

It is more likely than not, to a reasonable degree of medical certainty, in my medical opinion scanning over 34 years, that ___________’s death was triggered by a stress producing occurrence or event, directly related to his employment and that his death was work-related.

Thank you so very much for allowing me to review this case.

Carolyn Hartsell BSN, RN, CLNC