Medical Board Evaluation Test Report
MEDICAL BOARD EVALUATION TEST REPORT
I. Introduction
This report presents the findings of an independent medical evaluation conducted on John Doe by [Your Name], MD, on June 15, 2055. The purpose of this evaluation is to assess John Doe's medical condition regarding his disability claim following a workplace injury. The assessment includes a comprehensive review of medical history, physical examination findings, diagnostic test results, functional assessment, and impairment rating.
II. Medical History
|
Date |
Condition/Diagnosis |
Treatment/Intervention |
Provider/Clinic |
|---|---|---|---|
|
2048-2052 |
Lumbar spine injury |
Physical therapy, steroid injections |
Orthopedic Center |
|
2050 |
Anxiety disorder |
Cognitive behavioral therapy |
Dr. Sarah Johnson, Psy.D. |
|
2053 |
Hypertension |
Medication |
Primary Care Physician |
Summary:
Lumbar Spine Injury (2048-2052): John Doe sustained a workplace injury resulting in a lumbar spine injury. Treatment included a course of physical therapy and steroid injections at the Orthopedic Center.
Anxiety Disorder (2050): Diagnosed with anxiety disorder managed through cognitive behavioral therapy sessions with Dr. Sarah Johnson, Psy.D.
Hypertension (2053): Chronic hypertension managed with medication prescribed by the Primary Care Physician.
III. Physical Examination
|
Date |
Vital Signs |
General Appearance |
Systems Examined |
|---|---|---|---|
|
2055 |
BP: 120/80 mmHg |
Alert and oriented |
Cardiovascular, Respiratory, Neurological |
|
2055 |
HR: 72 bpm |
Well-nourished |
Musculoskeletal, Gastrointestinal, Dermatological |
|
2055 |
RR: 16 breaths/min |
No acute distress |
Endocrine, ENT, Psychiatric |
Findings:
Vital Signs (2055): Blood pressure within normal range, heart rate regular, and respiratory rate normal.
General Appearance: John Doe appears well-nourished and alert without signs of acute distress.
Systems Examined: Normal findings in cardiovascular, respiratory, neurological, musculoskeletal, gastrointestinal, dermatological, endocrine, ENT, and psychiatric systems.
IV. Diagnostic Tests
|
Date |
Test Type |
Results |
Interpretation |
|---|---|---|---|
|
2055 |
MRI Lumbar Spine |
Disc protrusion at L4-L5 |
Mild to moderate lumbar radiculopathy |
|
2054 |
EKG |
Normal |
No evidence of cardiac abnormalities |
|
2053 |
Blood Tests |
Elevated cholesterol levels |
It may require dietary modifications |
Interpretation:
MRI Lumbar Spine (2055): Identified disc protrusion at L4-L5 level contributing to mild to moderate lumbar radiculopathy symptoms.
EKG (2054): Normal sinus rhythm observed, indicating no cardiac abnormalities.
Blood Tests (2053): Elevated cholesterol levels noted, suggesting potential need for dietary modifications to manage cardiovascular risk factors.
V. Functional Assessment
A. Activities of Daily Living (ADLs)
-
Bathing and Dressing: John Doe demonstrates independence in bathing and dressing, although he reports occasional difficulty due to lumbar spine pain.
-
Mobility: Limited mobility was noted, particularly in activities requiring bending and lifting due to pain exacerbation.
-
Personal Hygiene: Able to manage personal hygiene independently with occasional assistance on days of increased discomfort.
B. Occupational Function
-
Previous Work Role: Unable to perform heavy lifting or prolonged standing, which are essential duties in his previous role as a construction worker.
-
Impact on Employment: Significant limitations in physical capacity affect his ability to engage in gainful employment without accommodations.
-
Recommendation: Vocational rehabilitation may assist in exploring alternative career options that align with his current functional abilities.
C. Cognitive Function
-
Anxiety Symptoms: Mild anxiety symptoms observed, particularly in stressful situations. However, cognitive function remains intact for decision-making and daily tasks.
-
Management: Continued cognitive behavioral therapy sessions are recommended to manage anxiety symptoms effectively.
VI. Impairment Rating
A. Overall Impairment
-
Overall Impairment Rating: The assessment reveals an overall impairment rating of 25%, primarily attributable to the chronic lumbar spine injury affecting physical capabilities.
B. Specific Functional Impairments
-
Mobility and Strength: Significant impairment noted in mobility and strength, particularly in the lumbar spine region, limiting activities requiring bending and lifting.
-
Emotional Regulation: Mild impairment observed in emotional regulation due to anxiety symptoms, although it does not significantly impact daily functioning.
C. Future Prognosis
-
Prognosis: With ongoing physical therapy, pain management strategies, and vocational counseling, there is potential for improvement in physical function and vocational outcomes.
-
Recommendation: Regular monitoring and adjustments to treatment plans are advised to optimize John Doe's functional abilities and quality of life.
VII. Conclusion
Based on the comprehensive evaluation conducted by [Your Name], John Doe presents with chronic lumbar spine pain and associated functional limitations. These impairments significantly impact his ability to perform essential job duties and activities of daily living. Recommendations include continued physical therapy to improve mobility, pain management strategies to alleviate symptoms, and vocational counseling to explore alternative career paths that accommodate his physical capabilities.
