Medical Case Scenario
DOI: 7/17/2015. Patient is a 44-year-old male welder helper who sustained injury when he lost footing and his left foot got caught and he twisted his knee. Per OMNI entry, he was initially diagnosed with left knee internal derangement. He is status post left knee arthroscopic surgery with chondral debridement, partial mereial mebsisccetomy and resection of anterior plica on 04/29/16. Per the IME performed on 09/01/16, the patient underwent a second arthroscopic procedure as related to the left knee in 06/2016. The claimant subsequently underwent approximately 30 sessions of physical therapy. The combination of surgery and therapy was really of no benefit to him with continued difficulties noted as related to the left lower extremity.
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whole person impairment rating is 1%.
Based on the medical report dated 10/26/16 by Dr. Huber, the patient has had a lot of issues with continued pain and swelling involving this left leg. He returns for follow-up.
He states he has constant pain and stiffness in the left knee with significant swelling in the left leg. He is having difficulty performing his work duties because of the pain and swelling. The functional capacity evaluation suggested he could not return to the duties he is doing. He cannot tolerate standing on his legs all day, he has significant residual effusion with any type of activity. He is taking Naprosyn and has been applying ice to his knee every day for the effusion and this does not control the swelling.
On examination, he has moderate effusion noted about the left knee and lower extremity. His clinical examination has not changed. He has obvious effusion comparing the left knee to the right. He is extremely frustrated at this point.
Assessment is status post left knee arthroscopy with medial meniscectomy and resection anterior plica with residual pain and
whole person impairment rating is 1%.
Based on the medical report dated 10/26/16 by Dr. Huber, the patient has had a lot of issues with continued pain and swelling involving this left leg. He returns for follow-up.
He states he has constant pain and stiffness in the left knee with significant swelling in the left leg. He is having difficulty performing his work duties because of the pain and swelling. The functional capacity evaluation suggested he could not return to the duties he is doing. He cannot tolerate standing on his legs all day, he has significant residual effusion with any type of activity. He is taking Naprosyn and has been applying ice to his knee every day for the effusion and this does not control the swelling.
On examination, he has moderate effusion noted about the left knee and lower extremity. His clinical examination has not changed. He has obvious effusion comparing the left knee to the right. He is extremely frustrated at this point.
Assessment is status post left knee arthroscopy with medial meniscectomy and resection anterior plica with residual pain and