AAPM&R National Grand Rounds: Disability Evaluation: Essentials of Reviews and Determinations-Case Study A

Case Study A

Pdf Summary

**Summary:**<br /><br />Dr. [Name omitted] conducted an Independent Medical Examination (IME) of Mr. Earnest Hurtman, a 35-year-old right-hand dominant male and electrician for GE since September 2018. Mr. Hurtman reported sustaining a work-related injury on March 1, 2021, when he tripped and fell, landing on his right side while working on an electrical panel. Post-injury, he experienced sharp pain in his right shoulder, rated 7/10. Initial X-rays showed no fractures, and he was diagnosed with a shoulder strain, receiving a ketorolac injection and medication.<br /><br />Mr. Hurtman underwent conservative care and saw a shoulder specialist, Dr. Carver, who diagnosed him with a full-thickness rotator cuff tear. He had arthroscopic surgery on May 5, 2021, including rotator cuff repair, subacromial decompression, and distal clavicular excision. Post-surgery, he followed up with Dr. Carver and was placed under physical therapy, later returning to work with restrictions. By October 15, 2021, he was deemed at maximum medical improvement with a 1-2% impairment rating.<br /><br />Currently, Mr. Hurtman continues to experience sharp, intermittent shoulder pain (level 7-8/10) and fatigue approximately 2-3 times per month, exacerbated by weather changes. These episodes last from a few hours to a day, managed with Tylenol. He reports discomfort lifting or carrying items above shoulder level and cannot comfortably participate in activities like swimming, frisbee golf, and cycling.<br /><br />Dr. [Name omitted] administered the Upper Extremity Functional Scale (UEFS), indicating a 42% perceived disability relative to his pre-injury baseline. Physical exams showed no visible atrophy or significant muscle weakness, except for mild shoulder dysfunction. He expressed a goal of continuing his job at GE despite concerns about his functional limitations. Overall, Dr. [Name omitted] did not observe signs of exaggerated pain behavior and noted normal neurological and musculoskeletal examinations with some shoulder-specific issues.

Keywords

Independent Medical Examination

Mr. Earnest Hurtman

work-related injury

right shoulder pain

rotator cuff tear

arthroscopic surgery

physical therapy

maximum medical improvement

Upper Extremity Functional Scale

functional limitations