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

Case Study B

Pdf Summary

**Summary:**<br /><br />Mr. Hurtman underwent an independent medical evaluation to assess his injuries following a work-related fall on February 25, 2021, which resulted in right shoulder trauma. Diagnoses include the history of the fall, post-surgical conditions like rotator cuff repair, subacromial decompression, and distal clavicular excision, with probable residual effects on his shoulder joints.<br /><br />The evaluation established a clear causal relationship between the workplace incident and Mr. Hurtman’s shoulder injuries, as he had no prior history of shoulder problems. The surgical procedures he underwent were deemed medically necessary and directly associated with his injury.<br /><br />Mr. Hurtman reached maximum medical improvement (MMI) on October 15, 2021. He was assigned a 10% upper extremity impairment (UEI) for the distal clavicular excision. Goniometric assessments of his shoulder range of motion revealed a combined 14% right UEI, factoring in motion deficits and functional baselines. A subjective functional review indicated significant losses in activities of daily living (ADLs) and hobbies like swimming and off-road biking.<br /><br />The assessment recommended permanent work restrictions to prevent reinjury, including avoiding forceful or repetitive activities at or above shoulder level, unilateral lifting limits, and conforming to "medium" work specifications outlined by the USDOL. If Mr. Hurtman’s current job cannot accommodate these restrictions, he may be eligible for further compensation.<br /><br />Dr. Able N. Willing, who conducted the evaluation, concluded the report with medical probability statements and reserved the right to reassess if new information arises.

Keywords

Mr. Hurtman

independent medical evaluation

work-related fall

shoulder trauma

rotator cuff repair

maximum medical improvement

upper extremity impairment

activities of daily living

permanent work restrictions

Dr. Able N. Willing