CASE EXAMPLES - CHRONIC PAIN CASE
Chronic Pain Case Report
DATE OF EVALUATION:
DATE REPORT INITIATED:
Gwendolyn Drawdy is a 52-year old Caucasian female seen for evaluation in the office of Paul M. Deutsch & Associates, P.A. unaccompanied in the evaluation. Her attorney, James H. Reiff, referred Gwendolyn for a rehabilitation evaluation. The purpose of this evaluation is to assess the extent to which handicapping conditions impede her ability to handle all activities of daily living, assess her future rehabilitative care needs and assess the disability's impact on her continued vocational status.
Client Name: Gwendolyn Drawdy; Social Security #: 328-98-1578; Address: 4249 Crystal Cove Loop, Cape Coral, FL 33861; County: Lee; Closest Metro Area: Fort Myers; Phone: 821-987-1235; Birthdate: 4/3/52; Age: 52; Sex: Female; Race: Caucasian; Marital Status: Divorced; Birthplace: Wales, Great Britain; Citizen: No; Elementary/Secondary Education: Elementary School in Wales. High School in Wales; Employer at time of injury: First UnitedMortgage; Position/Grade: Loan Officer; Bilingual: No; Glasses: Both; Dominant Hand: Right (No limitations); Height: 5’6”; Weight (present): 163 lbs.; Weight (pre-injury): 148 lbs.; Date of Onset: 9/8/02.
History: Gwendolyn notes she was struck in the back of the neck by a falling object, under which she was pinned. She indicates that it is hard for her to answer whether she had a period of loss of consciousness. She was sitting in the chair and the next thing she recalls is lying in the dirt but she does not recall anything in between. She believes people around her pulled the object off of her and freed her. An ambulance was called and she was treated at the scene. She was transported to Lee Memorial Health System on 9/08/02 where she was seen and treated in the ER. X-ray and CT of the cervical spine revealed a C6-7 dislocation of nearly 50% with bilateral jumped facets. Due to MRI incapability, Gwendolyn was transferred to Ascension Hospital for an MRI and a neurological consultation at that facility. Gwendolyn was stable at time of transfer.
Loss of Consciousness or Altered State of Consciousness: Unsure but certainly dazed.
Length of Unconsciousness or of Altered State: Very brief.
Independent Recall: Full recall of treatment at the scene and transport to the hospital.
Rehabilitation Program(s) [In/Outpatient Since Injury]:
Gwendolyn was transported directly from Lee Memorial Hospital on 9/8/02 to Ascension Hospital where she was treated and admitted. MRI of the cervical spine on admission revealed post traumatic sequela at the C6-7 level with disruption of the anterior and posterior longitudinal ligaments as well as interspinous ligament, with anterior subluxation of C6 on C7. It also showed accompanying prevertebral and small epidural hematoma accompanying spinal central canal stenosis with cord compression.
Gwendolyn was taken to surgery where it was confirmed that the disk as well as all other ligaments more posterior were disrupted. Reduction was achieved and fusion of C6-7 was accomplished without complications. Following surgery, improvement was noted with regard to arm symptoms but residual symptoms remained. Arm weakness, particularly in the hands was noted. Following surgery, Gwendolyn complained of significant anxiety. She was seen by psychology and psychiatry and started on medications including Paxil and Ativan. She began physical therapy (PT) and occupational therapy (OT) while in Ascension Hospital and at the time of discharge she was able to stand with supervision, ambulate 200 feet with a rolling walker with step-through gait, with cueing.
She was discharged on 9/16/02 with the assistance of LPN and RN nursing and therapy through Lee Memorial Home Health from 9/17/02 through 10/16/02. She also had home visits from PT and OT. Initially nurses visited daily for approximately one hour for dressing changes and to check her vital signs. Family and friends provided around-the-clock care. Nursing was gradually phased out by 10/16/02. PT and OT was provided three times per week until she could begin outpatient therapy in December 2002. She began outpatient therapy at Lee Memorial Rehabilitation on 12/17/02 and participated through 1/29/03. Although records are incomplete PT appointments were noted intermittently through 2004. OT ended in June 2004, “when I lost my job with First United and I no longer had insurance. I went on to a COBRA insurance and the current neurologist does not want me to restart PT until he goes in and deadens the nerves, so we are holding off on therapy for now.”
“I also went to a psychiatrist for depression and anxiety. I saw Ian Hull, a nurse practitioner in the psychiatrist’s office. I saw him throughout 2003 but I don’t recall when I first went there. I am still seeing him although not as often” .
Prior Medical History: She had an AC separation from a MVA in 1996 or so; she was off work approximately 3-8 months, but she was unable to recall exactly. She did not have surgery from this injury.
No history of use of psychotropic medications until after this injury.
No report of any other injuries, illnesses or accidents resulting in a disability.
Disabling Problems: (By client/family history and report. No physical examination occurred).
Gwendolyn: “My diagnosis as far as I have read is that I had a fracture of the cervical spine that was fused. That was the only thing I know that was addressed. Nothing was ever mentioned except my neck. So I thought all of the weakness in my arms and legs came from that injury primarily because of nerve damage. But two years later I am having problems not only with my neck but my thoracic area and both my lumbar and coccyx area. I have trouble sitting, walking and driving for any length of time. This trip here was excruciating and I had to stop many times for a break. I had pain going down the back of both of my legs, spasms in my buttocks and shooting pains up from the lumbar area upwards. I have a constant burning sensation in my bottom where the tailbone is. I have difficulty bending over. I tire very easily. If I do anything like trying to pick up roof shingles and tacks after the hurricane, I end up in a lot of pain because of it. I have to lie down quite often during the day because it is the only thing that seems to take a lot of the pressure off of my back. I remember my daughter took a picture of me while I was in the hospital and I had a bruise all the way around my low back and I think I broke the chair as I hit the ground with my low back. My doctor never addressed those issues but I could never ask him questions because he was never approachable. He would always make me feel like a fraud and I would leave his office in tears.
My current doctor had scheduled me this Thursday for an Epidural Nerve Block to see if that helps the pain. If that does not work he then feels I would need surgery. Unfortunately I will likely have to cancel the procedure because Blue Cross/Blue Shield of Florida has my COBRA and they canceled me when my payment blew away with the local post office in the hurricane. I am appealing but they indicated they still might not reinstate me” .
Low Back over the sacrum: Never pain free in this area but the pain varies in intensity. The pain is described as a constant, burning sensation. She is very sore to the touch in this area and she is frequently bothered by shooting pains. If she sits for a prolonged period the pain radiates down both legs and she begins to experience a surface numbness. The only relief is lying down and it is only partial relief. The lowest level of pain in this area is rated at a four. The average pain experienced in this area is a five to six. The worst pain level is a seven to eight and is experienced daily and usually by the end of the day. “The more I do the more it hurts”. The burning from the sacrum spreads into both buttocks.
Low Back/Lumbosacral area: Never pain free. The pain varies in intensity and is described as a constant, dull pain. The lowest level of pain is described as a two. The average pain is a four while the worst is a six. It gets to a six daily and again it is toward the end of the day and dependent on activity levels.
Mid Back/Thoracic: Never pain free but it varies in intensity. She rates the lowest level of pain as a two while the average is a four and the worst is a six unless you touch it and then it goes up to an eight. “I frequently have to take my bra off at home because I can’t even stand to have that touch it back there.” This also gets to the higher levels by day’s end.
Cervical: Always present. “It always remains around a level four although if I exert myself it can exceed a four. It can move up to an eight if I try pick up around the yard or if I pick up my grandson.”
Headaches:“I get headaches daily in one form or another. There are times I am headache free such as in the morning when I first wake up. The lowest level of headache is around a two while the average is a three and the worst is a four or five”.
Fingers of Left Hand: It is the index, middle and ring finger of the left hand that she reports as being numb on a constant basis. This results in frequent typographical errors on the keyboard and frequent dropping of objects.
Bilateral Forearms: There is intermittent numbness and tingling in the forearms and there can be shooting pains in the forearms as well. She feels that holding or grasping things in a certain way will precipitate the numbness and tingling. “I think I have nerve damage in my neck and I think this is what is causing the shooting pains and the tingling and numbness. I feel it more on the left but I can get it on both sides.”
Anticipated Treatments: Epidural Nerve Blocks and possible additional surgery to the neck above the fused area and to the sacral area or coccyx. (Dr. Francis Hisgen in Fort Myers).
Patient: Admits to depression and anxiety but feels the Effexor has helped a great deal. Notes that in the beginning she had panic attacks, agitation and severe anxiety. She feels she has improved significantly.
Family, Emotional Impact on Spouse/Children: She is residing alone. She has two daughters ages 32 and 30. She has one grandchild. She feels that the family is doing reasonbly well. Her grandchild is autistic and her daughter is a single parent. She would like to be much more help to her daughter but she is not physically able to be there for her to the extent she feels she would have been had it not been for this accident.
Loss of Tactile Sensation: Left hand, middle three fingers; sometimes in both forearms, and both legs (if sitting too long, or driving), numbness and altered sensation in the buttocks down to the ankles on the posterior portions of these areas. This is relieved by standing up and taking pressure off her lower back.
Reach: She can demonstrate a normal ROM in the upper extremities, but she would have pain on reaching and stretching with her arms up above her head.
Lift: She can only lift a gallon of milk from the refrigerator with both hands. She can manage a half of a gallon without problem. Using liquid detergent in the large containers is difficult as well.
Prehensile/Grip: Her grip strength appears to be intact, but she tends to drop things from the left hand frequently. She thinks this is because she has numbness on the three fingers mentioned previously.
Sitting: She can sit for approximately an hour before she would need to stand up and relieve the pain.
Standing: She can only stand about five minutes before she needs to sit down for a brief period. She progressively becomes more fatigued as the day goes on.
Walking/Gait: She used to walk for two miles and then she would come home and walk each of her four dogs for 45 minutes each. She can only walk to the corner and back now, which is approximately five minutes.
Bend/Twist: She can bend forward, but this would be quite painful. She cannot twist.
Kneel: She can kneel, but she is unable to rise without assistance. She cannot do this repetitively.
Stoop/Squat: She can stoop and squat, but she is unable to rise without assistance. She cannot do this activity repetitively.
Climb: She must hold onto handrails. She worries about her balance.
Balance: She describes this as “sometimes this is off”. She has trouble walking on uneven terrain.
Breathing: She describes shortness of breath due to deconditioning and anxiety.
Headaches: See Chief Complaints.
Vision: Double vision at times, usually when watching TV while she is in bed.
Hearing: Conversationally intact.
Driving: She is able to drive, but limited due to sitting restrictions. She tends to move her entire body rather than just turning her neck, when trying to see from side to side.
Physical Stamina (average daily need for rest or reclining): She feels she is about 50% of where she was pre injury.
Problems on exposure to:
Air Conditioning: Yes, more so. She does not specifically notice too much difficulty, but she does chill.
Heat: Yes, less of a tolerance. She thinks this might be related to menopause.
Wet/Humid: Yes, she begins to experience more pain when it is rainy or stormy.
Sudden Changes: Yes.
Fumes: She lost her sense of smell for about 11 months, but it seems to have returned now.
Stress: Yes, tends to become overwhelming.
Other: She feels she needs more tranquility than she did before.
Present Medical Treatment
Doctors Specialty Phone Fax Frequency Last Seen
Franklin Kilborn MD
Fort Myers (Primary Care Associates)
Francis Hisgen MD
3 X only
Ian Hull, Nurse Practicioner
Psychiatric Nurse Practicioner with The Phlox Clinic in Fort Myers. Dr. Mohler is the physician there, but she has never seen him.
Cecil Stephens, PT
Additional Therapies/Notes: She is no longer receiving therapy from Cecil Stephens because she lost her insurance coverage when she was terminated from First United. She did not realize at the time that she was eligible for Cobra; she subsequently went on Cobra, but she had already terminated with PT. Her payment for the Cobra insurance was lost in the mail when the hurricane destroyed the post office. Since the insurance company had not received her check, she was then cancelled. She plans to call the insurance commissioner to try to get reinstated.
She was told by Dr. Kilborn not to have more therapy until after she had an additional procedure. She was supposed to have an Epidural Nerve Block on 10/14/04 as a temporary fix, but she had to cancel this because she found out she has no insurance. She was told that if this did not work, surgery would be discussed (in the coccyx area). She was also told she would need more surgery on her neck above the level of the fusion as the upper part of her neck is becoming compromised and she may need additional surgery.
After First United she went to a small brokerage firm in Fort Myers and this business’ building was destroyed during the hurricane. She is unable to operate out of her house at the moment, as her house was also severely damaged in the storm.
Over-the-Counter Medication(s): None.
Drugstore: Walgreens Drug Store – Cape Coral
Assistive Devices: None - she has manual wheelchair, shower seat, single point cane, but she does not use these.
Date of Medical Summary: 10/7/04
Gwendolyn Drawdy is a 52-year old Caucasian female who sustained an orthopedic injury as a result of being struck on the back of her neck by falling debris. There is no history of loss of consciousness.
LEE MEMORIAL HOSPITAL: 9/8/02
Arrived via ambulance. History indicates debris fell on the back of her neck while she was in a seated position. Upon arrival to ER, she complained of neck pain, arm pain and weakness and numbness in the arms. Past medical history was significant for hypertension, hypothyroidism, arthritis and angina. X-ray and CT of the cervical spine revealed a nearly 50% C6-7 dislocation with bilateral jumped facets. Due to MRI incapability, Gwendolyn was transferred to Ascension Hospital. Plan was to obtain MRI and neurological consultation at that facility. Gwendolyn was stable at time of transfer.
ASCENSION HOSPITAL: 9/8/02 – 9/16/02
Transferred from Lee Memorial Hospital. MRI of the cervical spine on admission revealed post traumatic sequela at the C6-7 level with disruption of the anterior and posterior longitudinal ligaments as well as interspinous ligament, with anterior subluxation of C6 on C7. It also showed accompanying prevertebral and small epidural hematoma accompanying spinal central canal stenosis with cord compression.
Gwendolyn was taken to surgery and severe injury was confirmed. The only intact ligament was her anterior longitudinal ligament. The disc itself, as well as all other ligaments more posterior, were disrupted. Reduction was achieved and fusion of C6-7 was accomplished without complications. Following surgery, improvement was noted with regard to arm symptoms but residual symptoms remained. Arm weakness, particularly in the hands was noted.
Following surgery, Gwendolyn complained of significant anxiety. She was seen by psychology and psychiatry and started on medications including Paxil and Ativan. The medications helped considerably. She was anxious about the possibility of arm injuries having been missed on earlier evaluation. Subsequently, bilateral x-rays of the UE’s were performed and the only abnormality found was a known previous left acromio clavicular joint separation.
Gwendolyn participated in PT and OT and progressed well. At time of discharge, she was able to stand with supervision, ambulate 200 feet with rolling walker with step through gait with cues to increase right step length. OT reported that she would benefit from hospital bed, 3-in-1 commode to elevate toilet height and rolling walker. Follow up with primary care physician and psychiatric care was recommended. Gwendolyn declined inpatient rehabilitation program and was discharged to home. She also denied the need for a home health aide as her daughter would be staying with her. Discharge diagnoses:
- Cervical dislocation C6, C7 with central spinal cord injury
- Generalized anxiety disorder
LEE MEMORIAL-HOME HEALTH: 9/17/02 – 10/16/02
Gwendolyn participated in PT and OT in her home. Goals of physical therapy were to transfer and ambulate independently. Goals of occupational therapy were to increase hand control for opening packages, buttoning, carrying small items and simple ADL’s as well as to become independent with home exercise program for bilateral UE coordination and control.
LEE MEMORIAL REHABILITATION: 12/17/02 – 1/29/03; 3/11/03 – 1/13/04 (Incomplete Records).
Lee Memorial Rehabilitation: 12/17/02 – 1/29/03
Participated in outpatient PT program. Gwendolyn presented due to decreased upper and lower extremity strength. She had 4/5 strength in UE’s with exception of triceps which was 3/5. She transferred independently. A cane was used for ambulation and LE’s were uncoordinated. She was slightly unsteady. Sitting balance was good and standing/dynamic balance was fair. She had flexor tone in bilateral hands but could fully move fingers and wrist. She reported feeling pain all over her body and that she had to sleep sitting up. She felt her whole body was weak and her balance was “off”.
PT discharge summary of 1/29/03 indicates that Gwendolyn last attended PT session on 1/13/03. She reported she was feeling her balance was improved and she was feeling stronger. She was hospitalized and would see Dr. Nolen for a new prescription. She would be re-admitted with new prescription.
Lee Memorial Rehabilitation: 3/11/03 – 1/13/04
Gwendolyn was re-admitted to physical therapy. In letter dated 6/20/03 by the physical therapist, it states that Gwendolyn had improved function, strength, endurance and stability in PT. He felt Gwendolyn was on her way to a full recovery. She had set appropriate goals and hoped to return to work in the fall. In order to return to a fully functional independent individual, she would require continued aggressive PT to prepare her for her return to the community. Her physician, Dr. Kilborn, and the PT felt three months of rehabilitation would suffice.
Last PT progress note dated 1/13/04 indicates that Gwendolyn reported she was “doing okay”. Pain without brace was 6-7/10 on a 1-10 pain scale and 4/10 with the brace on. She reported she was able to get up from the floor by herself now.
SCHUDE, LEONARD M.D.: 9/19/02 – 5/12/03
Schude, Leonard M.D.: 9/19/02
Neurosurgical follow up. Gwendolyn felt she was doing well overall, but still had expected symptoms of pain across the shoulders, some pain radiating down lower in the thoracic spine region, dysfunction of fine hand movements, numbness of the hands and difficulty sleeping. She also noted some change in vision that was possibly related to the myosis associated with narcotics, but she planned to see her ophthalmologist if that did not improve.
Gwendolyn walked with a walker. She was advised by her therapist that she had some mild right leg weakness and she did seem to drag that leg a bit. She did have fairly good strength when individual muscle groups were tested. In the UE’s, she still had fine motor dysfunction in the hand. She also complained of a sore mouth and possibility of thrush.
Nystatin Swish prescribed for thrush. She was advised to continue with home therapy. Massage was approved if she maintained herself in the collar. She asked about some type of electrical stimulation by an acupuncturist and that was also approved.
Schude, Leonard M.D.: 10/3/02
Still reported hand weakness and numbness, particularly in the left arm. She was walking without the walker and continued wearing a cervical collar. X-rays showed good alignment. Advised to try to wean off narcotics.
Schude, Leonard M.D.: 11/7/02
Main problem was depression. She still had pain in the neck but had decreased her use of Percocet. Numbness persisted but she was improving. She had a cane with her but could walk without it. Examination revealed weakness of the arm, particularly on the left side. It was most notable for triceps, wrist extensors and grip. Gait without the cane was essentially normal. She could also walk well on the heels.
Weaning out of collar recommended. She could use a soft collar, as needed. She was advised not to do specific neck ROM exercises; simply the normal day’s activity would gradually return her neck ROM.
Schude, Leonard M.D.: 12/5/02
Gwendolyn was improving. She did not start PT yet because of depression but was not feeling better. She still had some left arm and hand dysfunction. She complained of short-term memory loss, but wondered if it was due to medication. She was taking Paxil, Xanax and a pain medication. On examination, gait was normal. She still had weakness in the interossei, left wrist extension and left triceps. There was some weakness on the right but less significant.
Schude, Leonard M.D.: 1/23/03
Letter to insurance company stating he deferred PT management to Dr. Scott Nolen. He noted he expected Gwendolyn to require PT for strengthening the arms and legs. As for driving, Gwendolyn was allowed to drive if she felt comfortable with it.
Schude, Leonard M.D.: 1/31/03
Gwendolyn was participating in PT. She still had fear of being out of the collar and was using it when driving and sleeping. She was encouraged to wean completely out of the collar as it was no longer necessary and might actually cause some neck pain due to deconditioning at this juncture. She was walking reasonably well and had good hand function with some slight weakness, as before.
Schude, Leonard M.D.: 3/10/03
Presented to discuss questions. Gwendolyn had a list of issues, none of which sounded neurological with exception that she felt she was having persistent difficulty with walking and balance and problems with cognitive dysfunction as well as some changes in hearing. MRI scans of relevant areas were ordered. She later reported that she was having pain in the lower back. There were a number of issues she wanted to discuss, related to her psychiatric problems, a drug addiction program she was entering to wean off narcotics and problems with Dr. Nolen and a loss of insurance coverage. She was also worried about driving. He believed he had talked to her about clearing her to drive previously, but she did not recall that. She reported that she simply could not move her neck; therefore, it would not be safe to drive. Therefore, she was told not to drive. It was not clear to examiner why she could not move her neck at all. She had a fusion at a single level, but in the office, she would only keep her head completely still and move her trunk, totally. That appeared non-physiological. On the other hand, she clearly had a major injury.
He told Gwendolyn that she simply did not need to wear any type of collar any more. He told her not to drive, because she still had not adequately improved neck motion. He told her that she still needed to see a physiatrist, who could take care of most of the issues for her, since they were basically rehabilitation issues. However, from a neurosurgical perspective, he needed to check her anatomy to be sure there was no ongoing injury problem, problem with the previous surgery, unrecognized injury to the head or neck or development of any new problem in the lower spine. MRI’s of the brain, cervical, thoracic and lumbar spines were ordered.
Schude, Leonard M.D.: 5/12/03
Gwendolyn reported she was improving considerably with PT. She had more neck ROM, though it was still quite restricted and she was still too anxious to drive. She continued to have weakness that affected the left arm and some problem in the left leg, including some clonus type symptoms, all as before. Examination revealed she did have some restoration of neck ROM but it was still quite restricted. She still had weakness of the left arm, affecting primarily the grip, elbow and wrist extensors. Her gait was nearly normal.
The only finding on MRI with regard to the cervical spine was mention of “fluid” in the dictation but he did not see anything that was considered abnormal for the postoperative state. She did have spurring of C5-6 with some narrowing of the canal, but no significant compression of the spinal cord.
Plan at this point was to simply follow Gwendolyn clinically and reserve any further imaging for the development of any new clinical findings, such as new signs of myelopathy or radiculopathy.
PRIMARY CARE ASSOCIATES/FRANKLIN KILBORN, M.D.: 9/23/02 – 10/2/03
Primary Care Associates: 9/23/02
Presented with complaint of pain in neck following cervical surgery two weeks earlier.
Primary Care Associates: 12/12/02
Complained of difficulty sleeping. Requested cholesterol and TSH check.
Primary Care Associates: 2/10/03
Gwendolyn complained of hot flashes, high anxiety, and chest and back pain. She needed new medication prescriptions. (Remainder of record is illegible).
Primary Care Associates: 3/17/03 – 10/2/03
Records are illegible.
NOLEN, SCOTT M.D.: 10/3/02; 11/6/02; 1/29/03
NOLEN, SCOTT M.D.: 10/3/02
Gwendolyn reported she was participating in PT and OT since discharge from hospital following C6-7 fusion.
Review of systems revealed occasional headaches. No blurred vision or memory loss were reported. Gwendolyn was totally independent in all activities of daily living. On examination, she had RUE full active ROM. She had LUE shoulder flexion to about 130 degrees; elbows, wrists and digits had full ROM. Impression:
- Impaired gait and mobility secondary to deconditioning
- S/P C6-7 fusion
- Mild depression
- Gastroesophageal reflux disease
Nolen, Scott M.D.: 11/6/02
Gwendolyn completed home therapy. She still had pain in the neck and shoulders.
Nolen, Scott M.D.: 1/29/03
Gwendolyn wanted re-evaluation for more therapy. She had pain in the neck and shoulders that was rated a 7 on a 10-point pain scale when not on medication. She was still having trouble sleeping. She was ambulating with straight cane, gait was unsteady. Impression:
Recommendations included continued PT in the home. Goals were to help her progress from a rolling walker to a cane or be independent.
RICHARDSON MEDICAL CENTER: 10/3/02; 11/7/02; 12/5/02; 1/30/03
Richardson Medical Center: 10/3/02
Cervical spine x-rays revealed fusion of the C6 and C7 vertebral bodies.
Richardson Medical Center: 11/7/02
Cervical spine x-rays revealed no change since 10/3/02.
Richardson Medical Center: 12/5/02
Cervical spine x-rays revealed fusion of the C6 and C7 vertebral bodies.
Richardson Medical Center: 1/30/03
PHLOX CLINIC, INC./KURT GREENLAW, M.D.: 1/20/03 – 10/31/03
Cervical spine x-rays revealed fusion of C6 and C7 vertebrae. There was no motion at those levels and normal range of motion of the upper cervical vertebrae.
Phlox Clinic, Inc.: 1/20/03
Referred by attorney for evaluation of depression. Gwendolyn reported nightmares. She became teary eyed when describing the trauma. She had a very good paramedic that she felt saved her life. She was overwhelmed with the support of friends and family who had stepped up to help take care of her.
Prior to the traumatic event, she only had symptoms of what she described as anxiety that started when she took her last job which was very high stress.
There was a strong family psychiatric history. Father was bipolar, her brother and sister were probably bipolar. Her daughter was possibly bipolar. Her brother’s son had ADHD and a cousin’s son had schizophrenia.
On Mini Mental Status Examination, she was cognitively intact. She was oriented, although she described herself as having some memory deficits, poor concentration, difficulty sleeping, low self-esteem, and feeling of embarrassment at her helplessness. And although she described her mood as a 7-8 on a scale of 1-10, she was teary eyed throughout most of the session. She admitted in the process of the assessment/discussion that she tried to put up a good front but that when she was alone and quiet and by herself, that her mood most likely was much different than what she was verbalizing. She had good insight, good judgement and demonstrated a strong potential for stabilization and recovery. Impression:
|Adjustment Disorder vs. Major Depressive Disorder
Fractured neck, hypertension and low thyroid
Severe related to the change in her work, the change in
her health and the change in her finances
Current GAF = 50-60, highest in past year 80-90
Gwendolyn had a good understanding of the contributing factors to her current state of depression including her use of OxyCodone, the changes in her life and her stressors. She also could verbalize how her family history of mental illness in combination with the severe current life stressor was possibly producing a mind/body dual action trigger of the depression. Plan was to return in one week to develop treatment plan from a psychotherapeutic perspective.
Phlox Clinic, Inc.: 1/28/03
Gwendolyn reported that over a three-day period, she had three episodes of chest pain that became progressively worse and ultimately resulted in her being seen in the ER. It was discovered while there, that she had an ulcer. Signs and symptoms of her depression were starting to improve. She wanted to give medication a little more time.
Phlox Clinic, Inc.: 3/3/03
Reported an increase in crying, depression and anxiety. She spent most of session in tears and described difficulty with her memory at times.
Phlox Clinic, Inc.: 3/7/03
Gwendolyn stated she was having more depression, short-term memory problems, crying and increasing anxiety.
Phlox Clinic, Inc.: 3/14/03
Gwendolyn began her OxyCodone taper on Monday by 1/2 tablet and was starting to experience opiate withdrawal symptoms including muscle pains, hand tremors and sweats. Her affect varied throughout visit from laughing, smiling, bright eyes to crying to appearing depressed. There were symptoms of opiate withdrawal. She seemed to have no visible signs of discomfort throughout visit. Plan was to continue to decrease OxyCodone by 1/2 tablet each week.
Phlox Clinic, Inc.: 3/24/03
Gwendolyn continued on opiate detox schedule. She was still irritable but the other signs and symptoms of detox seemed to be subsiding some. She was much less depressed and scored a 16 on the Hamilton Rating Scale for Depression.
Phlox Clinic, Inc.: 4/4/03
Reported she was down to 4 1/2 pills of OxyCodone a day. She was having more severe hip and pelvis pain. She was able to get down to 2 Xanax a day from 4/day. She reported she felt better mentally than she had in a long time. She was stable on 37.5 mg of Paxil.
Phlox Clinic, Inc.: 4/18/03
Gwendolyn was ready to decrease her OxyContin (record says “OxyContin” but should say “OxyCodone”) to four tablets per day. She was at two Xanax a day and was having considerable anxiety issues. She stated she moved the hospital bed out of the house and was doing 100% better with sleeping and pain issues. She scored a 24 on the Hamilton Rating Scale for Depression. Plan was to remain on four OxyContin tablets and increase Xanax to 2 1/2 tablets daily.
Phlox Clinic, Inc.: 4/25/03
Gwendolyn stated she was in complete panic yesterday. She was reportedly sitting on her patio reading her MRI reports when a little tornado picked up her patio umbrella. She could not bend backwards to look up to see where it had gone and it came crashing right down on her head. When that happened she felt paranoid. She felt that “who now is out to get me.” She went into the house and had feelings of agoraphobia. She stated she wanted to get off the pain pills entirely. Pain medication remained at 4 per day. Xanax continued at 2 –2 1/2 day.
Phlox Clinic, Inc.: 5/16/03
Reported she was down to 3 pain pills per day and 2 1/2 Xanax and wanted to stay at that dose until she was through with PT due to pain. She was not using her cane and had her neck brace off. Regimen continued.
Phlox Clinic, Inc.: 5/30/03
Gwendolyn reported she had to increase her pain pills to four. She was going through very hard PT with no massage being done. She had constant headaches. She had all the symptoms of anhedonia. She was crying at times throughout the session and felt that she was regressing. Score on the Hamilton Rating Scale for Depression was 33. Her depression had progressed to a severe state. Paxil was discontinued and Effexor XR 37.5 mg was prescribed.
Phlox Clinic, Inc.: 7/1/03
Gwendolyn stated, “ I’m beginning to feel wonderful, my focus is back. I get so busy some days I forget to take my pain meds.” Then she reported that she had opiate withdrawal signs and symptoms. She felt Effexor was the drug of choice. She still wanted to taper off of her narcotic pain pills with plans to return to work on a limited basis starting around 9/1/03. Effexor increased.
Phlox Clinic, Inc.: 7/25/03
Gwendolyn reported things had improved in her life since she received some financial income, which relieved a lot of stress. She was walking without a cane. She had bright affect and there was music in her voice. She felt the Effexor had her depression stabilized. She continued with aggressive PT. Regime continued.
Phlox Clinic, Inc.: 10/27/03
Gwendolyn reported significant difficulty trying to readjust to going back to work. She had been working for the past eight weeks. She was struggling with work having to totally rebuild her clientele in the mortgage business and she did not have the energy. She was down to a couple of Xanax and a couple of pain pills a day but was continuing to struggle severely with those issues. Regime continued.
Phlox Clinic, Inc.: 10/31/03
Gwendolyn continued on pain medication and Effexor. She felt that taking the additional Effexor at bedtime was helping. She was on 300 mg in the a.m. and 75 mg at night. Plan was to continue to monitor her and adjust medication as needed.
ST. ANNE MEDICAL: 4/8/03
IMAGING CENTER OF CAPE CORAL: 4/10/03; 4/15/03; 4/16/03
X-rays of the bilateral hips were negative.
Imaging Center of Cape Coral: 4/10/03
MRI of the lumbar spine was unremarkable.
Imaging Center of Cape Coral: 4/15/03
MRI of the thoracic spine revealed minimal endplate spur and disc bulge at the T3-4 and T4-5 levels.
MRI of the cervical spine revealed:
- Cervical fusion changes at the C6-7 level anteriorly and posteriorly
- Signal alteration involving the C6-7 disc interspace. It was possibly related to above/metallic artifact; however, low grade infectious etiology could give that presentation.
- Spurring and concentric disc bulging at C5-6 with moderate facet arthropathy. It flattened the thecal sac and there was borderline canal stenosis and foraminal narrowing. Both C6 nerves appeared abutted.
Imaging Center of Cape Coral: 4/16/03
MRI of the brain was unremarkable.
DEPOSITION OF GWENDOLYN DRAWDY: 12/19/03
Takes Norvasc for high blood pressure. She took this medication pre-accident but had to double up on medication since accident. Also takes Levoxyl for a thyroid condition (Pg. 11). Takes Effexor XR, 300 mg for depression and anxiety. “I am very depressed” (Pg. 12). She is also on Xanax (Pg. 13). Also takes OxyCodone. She has reduced the Xanax and OxyCodone a lot. She tried to get off it altogether but “I just can’t function without it so far.” She had reduced it from 16 a day down to one (Pg. 14). She is still seeing [Psychiatric Nurse Practitioner, Ian Hull]. (Pg. 15). Also takes medication for ulcer to coat stomach from medications (Pg. 16).
One of the reasons she reduced the medication was because “I’m having a lot of problems focusing. I was a very articulate person and I’m having trouble organizing—and memory, terrible, terrible memory problems. And one of the reasons I wanted to reduce the medication was to make sure that it’s not the medication that’s doing that to me. And since I’ve reduced the medication, I’m still having the same symptoms, so it is what it is, you know. I don’t think I will change, whether I drop that one pill or not” (Pg. 17).
She was educated in Europe and completed high school. She started college at the University of Cardiff in Wales but moved to the U.S. After divorcing her husband, she went to community college in Fort Myers and took some classes but did not obtain a degree (Pg. 23-24). She was a stay at home mom until her divorce (Pg. 25). She does not have a problem with long-term memory, just short-term (Pg. 26).
At the time of the accident, she was working for First United and had been there for four years (Pg. 29). She worked out of her home and was a loan officer. She went back to work in 9/03 part-time, three days a week for six hours a day. She is licensed through her company (Pg. 30). Prior to that, she worked for Burdines for about 13 years in major appliance sales. She left Burdines in 2001 (Pg. 31). When she went back to work in September, it was like starting all over again, because after being out for a year, she lost a lot of her realtor contacts (Pg. 32).
She has not made any money since she has been back. She received commission only that averaged out to be about 50 points per loan. Pre-accident, her income ranged anywhere from $35,000-$60,000/yr. Unfortunately the month she got hurt, she had 28 loans in her pipeline. She made $10,000 that month (Pg. 33). That was the beginning of the refinance craze. So her salary or commissions would have increased dramatically, had she been able to work. Her goal was $100,000 that year, and she thinks she could have passed that easily. Now, she calls her realtors and keeps in contact with trying to make new relationships over the phone, and is trying to learn the new software program, which is brand new. That is not going well (Pg. 33).
She can currently drive until her legs get numb and then can’t drive anymore so she tries not to drive long distance, especially if she is by herself (Pg. 35). She has to drive to meet clients. Her territory has changed because she is not able to drive from Cape Coral to Naples. Her territory is now local, which is going to impact her income (Pg. 37). She drives as little as possible. She drives usually about once a month. She does drive to run errands. She is afraid to drive long distances (Pg. 38). She started driving again in November after the accident. She never drives at night (Pg. 39).
She was denied social security disability benefits (Pg. 45). She currently had two loan applications in the works. She made $10,000 the month before the accident and $8,000 the month before that (Pg. 47). She had a previous car accident in which she sustained an AC (acromioclavicular) separation of her left shoulder (Pg. 49).
Prior to this accident, she has never been treated for mental health reasons (Pg. 55). She was never on medications for depression and anxiety (Pg. 56). She had good days and bad days in her life prior to the accident, but she did not experience major depression like she did after the accident (Pg. 57).
When not working, she spends most of her time resting and trying to keep her house clean. She tries to work in her garden a little (Pg. 58). Her daughter Patricia cleans her house frequently, as she can not do a lot of heavy things (Pg. 58).
She has had to borrow money from several people to pay bills and her mortgage (Pg. 59). She was behind on her bills for a long time. She had to take $20,000 out of her 401K (Pg. 62).
She has mentioned her memory problems to all her doctors (Pg. 72). She does not remember any doctor telling her she had a closed head injury (Pg. 73). She does not recall any doctor telling her she may need additional surgery. She was participating in PT twice weekly for her neck and arms and lower back to regain strength (Pg. 76).
Gwendolyn feels like she has a knife in the thoracic region of her back. The pain comes and goes (Pg. 77). It depends on what she does, if she sits too long. If it last longer than 15 minutes, she takes 1/2 of a pain pill and tries to lie down on a massage thing she has. Her skin feels like it has been burned when her therapist touches her. Therapist said that is probably nerve damage (Pg. 78). All her therapy has been at Lee Memorial (Pg. 79).
She has numbness and tingling in her arms and hands. She has it constantly. The fingers in her left hand are pretty numb all the time. She is right-handed (Pg. 79). The numbness never goes away. She is able to type on the computer but she makes mistakes and it takes her three times as long to do things she used to do because she has to check her spelling and all that. She does not have numbness and tingling in her right hand. She has numbness and tingling in her legs sometimes like if she sits too long and drives too long a distance (Pg. 80). “A couple of times I’ve been walking and my legs will just buckle.” They buckled a lot in the beginning and do so less frequently as time goes on. In the beginning, she would actually fall to the ground (Pg. 81). Her arms give way under her. “If I’m on the floor getting a VCR and I use my arms to get up, sometimes they give way under me.” She no longer uses a cane or walker (Pg. 82).
She currently has headaches every day that last all day. She did not really notice them until after she went off pain pills (Pg. 83). Since going off pain pills, she constantly has a headache, neckache, and mid and lower backache. She has pains in her legs if she drives too long or if she sits too long (Pg. 84). She also has pain below her collarbone especially since going back to work (Pg. 86).
PAST MEDICAL HISTORY
KUZNIK, TODD M.D.: 5/16/00; 5/30/00; 6/26/00
PRIMARY CARE ASSOCIATES: 1/12/01 – 4/5/02
Treated for hypothyroidism and chest pain.
Primary Care Associates: 1/12/01
Presented for blood pressure check. Assessed with hypertension and hypothyroidism.
Primary Care Associates: 2/8/01
Complained of muscle and joint aches, difficulty sleeping, chest pain and numbness on left side of face down left arm.
Primary Care Associates: 8/16/01
Gwendolyn complained of UTI and heart palpitations. Levaquin prescribed for UTI.
Primary Care Associates: 10/24/01
Gwendolyn complained of headaches and fatigue.
Primary Care Associates: 1/24/02
Complained of night sweats. Diagnosed with possible menopause.
Primary Care Associates: 4/5/02
Follow up for hormone replacement.
Records Reviewed :
LaBerge Healthcare, Inc./Equipment Invoices (In File)
Depositions Reviewed :
Phlox Clinic, Inc.: 1/20/03 – 10/31/03
Lee Memorial Home Health: 9/17/02 – 10/16/02
Lee Memorial Rehabilitation: 12/17/02 – 1/29/03; 3/11/03 – 1/13/04
Lee Memorial Hospital: 9/8/02
Richardson Medical Center: 10/3/02; 11/7/02; 12/5/02; 1/30/03
Schude, Leonard M.D.: 9/19/02 – 5/12/03
Income Tax Returns: 1998-2002 (In File)
Kuznik, Todd M.D.: 5/16/00; 5/30/00; 6/26/00
St. Anne Medical: 4/8/03
Primary Care Associates/Franklin Kilborn, M.D.: 9/23/02 – 10/2/03 Pre-Injury: 1/12/01 – 4/5/02
Ascension Hospital: 9/8/02 – 9/16/02
Imaging Center of Cape Coral: 4/10/03; 4/15/03; 4/16/03
Nolen, Scott M.D.: 10/3/02; 11/6/02; 1/29/03
Drawdy, Gwendolyn: 12/19/03
IMAGING CENTER OF CAPE CORAL: 9/23/04
HISGEN, FRANCIS M.D.: 5/8/03 - 10/5/04
CT scan of the coccyx revealed a degree of osteopenia. However, there was no discrete destructive bone lesion or discrete inflammatory reaction by CT criteria. If patient did not respond to appropriate therapy, then perhaps a radionuclide bone scan would be helpful to determine subtle abnormal activity in the area.
Hisgen, Francis M.D.: 5/8/03
Initial neurosurgical evaluation for neck and shoulder pain. Gwendolyn complained of constant ache across back of shoulders, occasional shooting pain to right jaw area, posterior rib cage pain in thoracic area, muscle spasms in right lateral and lower back pain, shooting down both buttocks. She also reported weakness of entire left side and numbness and tingling in fingers. She reportedly stumbled at time due to leg weakness. Physical examination revealed limitations of C-spine movement, weakness of UE’s and decreased sensation, especially in left hand. (Remainder of report is missing).
Hisgen, Francis M.D.: 1/22/04
Progress note states that with regard to numbness, Gwendolyn might require a splint during the evening to rule out carpal tunnel syndrome.
Hisgen, Francis M.D.: 9/16/04
MRI of the lumbar, thoracic and cervical areas was reviewed. Gwendolyn had minimal endplate changes in the T4-5 with some upper back pain. In the cervical area, she had C5-6 just above the level of the previous fusion with compromise of the nerve roots. In the lumbar area, there was no obvious disc herniation. It was possibly just muscular pain.
Gwendolyn was advised to have a course of PT. Her pain was way down in the coccygeal region, which had persisted for two years now. Therefore, she wanted something done. She was advised to have a CT scan to look for any changes, previous fracture and subsequent fusion there.
Hisgen, Francis M.D.: 10/5/04
Note is mostly illegible. May need radiofrequency rhizotomy of coccygeal nerve.
LEE MEMORIAL: 10/12/04
Gwendolyn underwent coccyx nerve block.
Lee Memorial: 10/12/04
Hisgen, Francis M.D.: 5/8/03 – 10/5/04
Imaging Center of Cape Coral: 9/23/04
DEPOSITION OF FRANKLIN KILBORN, M.D.: 11/18/04
Internist (Pg. 5). Board certified (Pg. 6). First saw Gwendolyn on 5/16/00 (pre-injury (Pg. 7). First visit post injury was with his associate, Dr. Vetter on 9/23/02 (Pg. 14).
On 3/17/03 visit, Gwendolyn still had significant pain and wanted further testing, including MRI. She had significant spasms in the neck and was having difficulty walking (Pg. 21). MRI revealed the possibility of a low- grade infectious etiology and spurring and disk bulging at C5-6 with moderate facet arthropathy. He then referred Gwendolyn to a neurosurgeon (Pg. 23). On April 7, 2003, she had new onset low back pain and MRI was ordered (Pg. 24). On 8/11/03, she was doing much better and was still on pain medication but lower levels. She was also on Xanax (Pg. 25). MRI was ordered for continued neck pain and was performed on 1/9/04. It showed S/P C6-7 fusion with anterior compression place in place. It was causing significant artifact from C5 to C7. It further stated patient would benefit from cervical spine myelogram (Pg. 29). On 10/21/04 visit, she complained of problem with short-term memory, of tailbone pain and headaches. She also had weight gain that partially was probably a congestive heart failure and she was retaining fluids. She was on Vicodin and an antidepressant (Pg. 30). He last saw Gwendolyn on 11/16/04. MRI was reviewed and showed C5-6 disk bulge and multi-nodular goiter. CT myelogram was recommended to determine if there was nerve compromise. Gwendolyn’s complaints were consistent with being hit in the back of the head as the history reflected (Pg. 32).
With regard to whether Gwendolyn suffered a permanent injury to the cervical spine, he states “ I have seen her from before the injury and I have seen her after the injury. I feel this lady, she was energetic, vibrant and every day was aggressive in life. And suddenly after the injury, she had completely withdrawn and in pain, not able to move and getting depressed and gaining weight. Emotionally and physically, I believe she has suffered a lot. And what the recent MRI shows, that probably after the CT myelogram, we’ll know more, but probably because of the fusion, that disk is probably giving her more problem. That’s why I have a referral to Dr. Hisgen, neurosurgeon, for further input from him” (Pg. 33-34).
Prior to Gwendolyn’s injury, he did not refer her to a psychiatrist (Pg. 42). February 10, 2003 was the first time Gwendolyn mentioned back pain. He ordered lumbar MRI on 4/10/03 (Pg. 43). It was unremarkable (Pg. 44).
He does not recall being contacted by vocational rehabilitation expert, Dr. Paul Deutsch (Pg. 48). He does not recall rendering any opinions to Dr. Deutsch. He has not come across any records from any physician or health care provider indicating that Gwendolyn needs additional surgery on her neck (Pg. 49). If the myelogram was positive, if there is compromising or narrowing of the spinal canal compromising the existing nerve, it will need a surgery.
DEPOSITION OF FRANCIS HISGEN, M.D.: 11/18/04
Neurosurgeon. Board certified (Pg. 8). First saw Gwendolyn on 5/8/03 (Pg. 9). Looking at axial views of the cervical spine, specifically C5-6, you can see that the cuff of the spinal fluid is no longer present anteriorly. That means something is pushing on that level to displace the spinal fluid and almost touching the cord of the ventral aspect of the wound (Pg. 17). With regard to whether that condition will likely stay the same or get better or worse over time, Dr. Hisgen states “Yes, it’s a slow, progressive type of situation. And sometimes, a patient goes for years or they might have mild pain and gradually get worse. But most often they get worse because it is a progressive deterioration of a degenerative condition“(Pg. 18).
Last visit was on 10/5/04. Coccygeal block was suggested. If that worked, radio frequency could be tried (Pg. 20). He doubts very much that the problems with the coccyx are in any way related to the accident with the tree hitting her (Pg. 21).
Gwendolyn did sustain a permanent injury to C6-7. Prognosis is that she will hopefully remain stable. There is the possibility of progressive degeneration at the C5-6 level, and eventually she may require surgical intervention in that area (Pg. 22). His charge would be between $5,000 - $7,000 (Pg. 23).
Gwendolyn’s osteopenia is not related to the accident. He doubts the minimal end plate spurring in the thoracic spine at T3-4 is related to the accident “unless, you know, the mechanism of the injury that took place with her, she had a complaint of the thoracic spine at the time when she had fallen with the tree. But I don’t have the details of that and I’m sure that they must have done an MRI at that time in Ascension Hospital (Pg. 27-28).
Gwendolyn complained of ability to use her left hand and said there was weakness and he did find weakness (Pg. 29-30). He does not know if Gwendolyn was compliant with recommended PT. She had not gone through with nerve block of the tailbone yet. He believes there is a good possibility she will have future surgery on the C5-6 area (Pg. 31). If she elects to have surgery, the procedure takes about two hours at one level and patients are in the hospital for 24 hours. Follow up visits would be required at one week, six weeks, three months and at the end of the year. If the fusion is good by x-ray, then no further treatment is necessary. From this day forward, Gwendolyn’s follow up care should be periodic, at least three times a year (Pg. 35).
DEPOSITION OF LEONARD SCHUDE, M.D.: 11/23/04
Neurosurgeon. First saw Gwendolyn at Cornerstone Hospital (Pg. 6). Performed surgery to neck on night of accident (Pg. 12). Reduction was achieved (Pg. 13) but not resolution of the symptoms. Gwendolyn did have residual symptoms and deficits. He noted particularly the weakness in the arms, particularly the hands. She continued to have problems with anxiety after the surgery and was seen by psychology and psychiatry and was placed on medication to help her (Pg. 14).
The hardware installed is to remain in for the rest of Gwendolyn’s life (Pg. 17). Gwendolyn’s pathology is consistent with history of being hit in the back of the head. He thinks he wrote somewhere in the chart that he had suspicion that Gwendolyn already had an anxiety disorder that was just exacerbated by the injury (Pg. 18).
During March 2003 visit, he told Gwendolyn he thought she could drive. She felt she could not move her neck well enough. Since she had only one segment fused he did not think this caused total loss of neck motions. She was still having trouble getting over it and was afraid to move her neck (Pg. 26).
He is not in a position to make a long-term prognosis, as he has not seen Gwendolyn in quite awhile. As of May 12, 2003 he did not foresee any future surgery. Gwendolyn had not recovered enough for him to make that a definite determination. The last time he saw her, it was not clear that she could return to work because of not only her spinal cord injury, but her other issue. Her psychological problem (Pg. 32). “So I think it was more a complicated decision, and the last time I saw her she still had a lot of residual deficits (Pg. 33).
The spurring at C5-C6 was generative because of the shape of it. He does not think it was result of the injury. The reason he did not think Gwendolyn had recovered enough to determine if she was ever going to need more surgery was because it was conceivable that she might need further surgery because of stress shifting, or whatever, to the next discs (Pg. 34-35). Surgery would use anterior approach and would involve removing the plate and putting a new plate just on the next disc.
Depositions Reviewed :
Schude, Leonard M.D.: 11/23/04
Hisgen, Francis M.D.: 11/18/04
Kilborn, Franklin M.D.: 11/18/04
LEE MEMORIAL: 1/22/03; 1/23/03
Lee Memorial: 1/22/03
2-Dimensional Color Doppler Studies revealed mild tricuspid regurgitation with pulmonary artery systolic pressure of 30 mmHg.
Lee Memorial: 1/23/03
IV Adenosine Stress Echocardiogram showed no evidence of myocardial ischemia by EKG or by echo imaging.
BLACK, GERALD PH.D.: 3/10/03 (Partial Report)
General clinical evaluation with a Mental Status Examination and Abbreviated Neuropsychological Screening for Office of Social Security Disabilities. Gwendolyn reported she was having symptoms of a head injury that she just recently began to notice. She described the symptoms as loss of short-term memory, balance problems, depression and anxiety. She said she thinks she hit her head on the ground but she does not recall, as she was unconscious when she fell. Medical documents provided diagnosis of C6-7 injury with central cord type deficits. (Next page is missing)
Tests administered: Modified Mini Mental Status Examination (3MS), Beck Anxiety Inventory, Beck Depression Inventory and the Wechsler Memory Scale-III (WMS-III). Gwendolyn was essentially cooperative, relevant and oriented in all spheres of the Mental Status Examination. She obtained a score of 97 n the 3MS, which fell in the Average range. Her hypothetical social judgement appeared to be good.
On the Beck Depression Inventory, Gwendolyn obtained a score of 24, which placed her in the Moderate range of depressive symptoms. On the Beck Anxiety Inventory, she obtained a score of 43, which indicated symptoms of severe generalized anxiety.
On the WMS-III (Wechsler Memory Scale, Third Edition), all test results indicated normal functioning relative to memory and attention and concentration (working memory) skills. In fact, her immediate visual memory fell in the Above Average range.
Gwendolyn appeared to understand the value of money and made independent purchases. Her mathematical skills appeared to be intact overall and she seemed capable of managing personal funds at the time. (Remainder of report is missing).
LEE MEMORIAL ORTHOPEDIC AND REHABILITATION CENTER: 3/23/04 – 4/30/04; 6/15/04 – 8/1/04
Lee Memorial Orthopedic and Rehabilitation Center: 3/23/04 – 4/30/04
Participated in PT. Progress note indicates Gwendolyn had 5/5 lower extremity strength. She was taking little or no pain medications. She still experienced intermittent headaches. She was able to drive but could not do other described functional activities. Continued PT recommended.
Lee Memorial Orthopedic and Rehabilitation Center: 6/15/04 – 8/1/04
Gwendolyn continued in PT. Progress report indicates she was off OxyContin and pain was rated 2 on scale of 1 to 10. Gwendolyn was back to work and driving. She still experienced cervical and upper back pain although reduced. Continued PT recommended.
RICCIO, JAVIER M.D.: 5/27/03
Neurological consultation for Medicare disability determination. Gwendolyn was seen in reference to her leg weakness and neck stiffness. She reported weakness in the leg, left more than right, and intermittent numbness and tingling over her LUE. At times, she described pain that was felt over the cervical paraspinal region. There was a stiffness felt over the cervical and thoracic paraspinal area. (Page 2 of report missing).
Examination revealed symptomatology compatible with cervical spondylosis.
PRIMARY CARE ASSOCIATES/FRANKLIN KILBORN, M.D.: 1/20/04 – 11/16/04
IMAGING CENTER OF CAPE CORAL: 10/22/04; 11/9/04; 11/10/04
Records are illegible.
Imaging Center of Cape Coral: 10/22/04
CT of the chest revealed:
Imaging Center of Cape Coral: 11/9/04
- Nodule lower pole of the left lobe of the thyroid that appeared to measure around 1.5 cm in size suggesting a probable adenoma.
MRI of the cervical spine revealed Gwendolyn was S/P fusion at C6 and C7 with an anterior compression plate in place. That was causing significant artifact from C5 through C7. She would probably benefit from a CT cervical spine myelogram for further evaluation. Radiologist did not see a large disc from C5 through C7. There did appear to be bulging of the annulus at C5-6.
MRI of the thoracic spine revealed small chronic Schmorl’s nodes involving the superior endplate of T4 and T5.
Imaging Center of Cape Coral: 11/10/04
MRI of the lumbar spine was unremarkable.
RYBKIN, PAUL M.D.: 10/27/04
Ultrasound of the thyroid revealed inhomogenous thyroid lobes, which probably reflected multinodular goiter.
PAST MEDICAL HISTORY
SOJOS, JULIAN, M.D.: 2/25/98 – 2/21/00
Followed for multiple thyroid nodules. Biopsies were benign. Synthroid and Levothroid prescribed.
Records Reviewed :
Lee Memorial Orthopedic and Rehabilitation Center: 3/23/04 – 4/30/04; 6/15/04 – 8/1/04
Riccio, Javier M.D.: 5/27/03
Primary Care Associates/Franklin Kilborn M.D.: 1/20/04 – 11/16/04
Black, Gerald Ph.D.: 3/10/03 (In File)
Sojos, Julian, M.D.: 2/25/98 – 2/21/00
Lee Memorial: 1/22/03; 1/23/03
Imaging Center of Cape Coral: 10/22/04; 11/9/04; 11/10/04
Rybkin, Paul M.D.: 10/27/04
SOGEGIAN, O., M., Ph.D.: 12/15/04
Vocational Rehabilitation Evaluation
Dr. Sogegian saw Ms. Drawdy on 11/5/04 for a vocational rehabilitation evaluation, in a court reporter’s office in Cape Coral, FL.
Ms. Drawdy indicated she was working about 15 hours per week and was compensated solely by commission on sales. She is fatigue and indicated she gets sore, and has significant pain in her lower back. She earns about $1,400 per month.
Summary and Impressions:
Dr. Sogegian reviewed an IME of 10/22/04 by Dr. Batley. Restrictions included avoidance of frequent activities above the shoulder and neck level.
Dr. Sogegian felt she would be able to participate in full time employment and that the injury did not cause a loss of earning capacity. The adverse impact to the local housing industry caused by Hurricane Charley, along with her termination from First United, confounded an analysis of how the 9/8/02 tree incident affected her career development and earning capacity. Regardless of any injuries she sustained because of the 2002 incident, these events would have been significant. Clearly, she is capable of engaging the work tasks she performed before the 9/8/02 incident. Record Reviewed:
Sogegian, O., Ph.D.: 12/15/04
Activities Of Daily Living
Arises: 5:00 a.m.
Retires: 9:00 p.m.
Average Hours Sleep/24 Hours:
Sleep Difficulties: She will awaken about every 1.5 hours after she falls asleep. She tosses and turns all night.
Dressing: Independent, but tends to wear flats and slip on shoes.
Housework: She can do some; her daughter helps her with housekeeping.
Cooking: Limited by time standing to cook complicated things. She has to be up and down, sitting and standing.
Laundry: This is painful to bend, “but I do it. I don’t want anyone else doing my laundry”. She does small amounts often.
Yard Work: Unable to do. She does try to get out for 15 minutes at a time to weed or tend her roses. Cannot mow the lawn.
Organizations Pre/Post: She mainly worked 12-14-16 hours per day, non stop.
Volunteer Work Pre/Post: Mainly working.
Socialization Pre/Post: Much less post injury.
Hobbies (Present): Gardening, dogs (the dogs have become more of a chore than a hobby now).
Hobbies (Previous): Cooking; Decorating, Gardening to a bigger extent.
History of Abuse and/or Treatment Programs: She had an alcohol problem in the past and stopped drinking about two weeks before the accident.
Spouse: Divorced for 25 years.
Children: 2 grown children.
Number in Residence: 1
Type of Residence: 1 story, damaged severely in the recent hurricanes.
Wages: Part-time work.
Other Agency Involvement
State Vocational Rehabilitation: No.
State Employment Services: No.
Rehabilitation Nurse: No.
Other Agency: No.
Felony Convictions? No.
Education & Training
Highest Grade Completed: Graduated High School in Europe.
Miscellaneous Education Information: Attended high school in Europe. She graduated in 1970 she thinks. She took some college courses in typing, etc. She lived in Wales and then moved to Chicago.
Released to Return to Work: Released to return to work.
Work History Since Injury: She first went back to work with First United the following September, 2003. She went back almost full time (6 hours per day) but because she worked on commission as a loan officer, she had lost a lot of her realtor contacts after having been off work so long. It took her from September to January 2004 to start bringing in business again. From January 2004 through June 2004 she continued working for First United Mortgage. On 6/3/04 she was terminated (new management) and she began at Brooms Mortgage the next day and she has been there ever since. She tried to work full time but was only able to manage 6 hours or so. The difference in the two employers is that with First United, she had an office in her home, so if she did not feel well, she could still work from home. (Territory with First United: Cape Coral to Naples prior to accident; then after the accident she stayed in her home area). When she went to work with Brooms, she went in to the office every afternoon. She felt she was a pioneer for a new company as all her contacts with First United were out of the area. With Brooms, she needed to develop a new source of realtors. She was able to work up to 6 hours per day at First United when she returned to work. With Brooms, she was able to manage about the same. She would still be there had it not been for the hurricane. The mortgage industry has really suffered after the storms. Had she not been injured and having the difficulties she is having, she would have picked up and moved to Tampa, Orlando or Ft. Lauderdale as the Mortgage industry is still going great in those areas. Her immediate supervisor at First United was Russell Anderson 561 987-3214; his supervisor is Edgar Rios, District Manager 305 312-8971. Both of these gentlemen indicated they would be able to give her a reference.
She has a loan officer’s license. To get her Broker’s License, she would have to take another course (a mortgage broker’s course). She does not know how long the course would be (subsequent research has shown a 3-day course, eight hours per day would be required, as well as taking an examination. A review crash-course would also involve eight hours of training). At the present time, she is working for a broker. If she was a broker, she would not have to get a quota of loans and she would be able to contract her own cases. She averaged 27 loans per month (minimum was 10 loans per month). She was paid strictly on commission. The first two years she maybe earned $36,000-$46,000. Then she indicated she began to earn more each month. The year she was hurt was likely the peak of the refinance season and she feels confident she would have made $100,000. She felt she would have been able to continue with this trend. She had participated in this type of work approximately seven years.
Employer: Brooms Mortgage Group; City/State: Cape Coral, FL
Position: Loan Officer
Start Date: 6/5/04; End Date: 8/13/04; Schedule: Full-time
Length: 2 months; Wage: Commission $5,000
Duties: Originated loans
Reason for Leaving: Hurricane Charley destroyed the office.
Employer: First United Mortgage; City/State: Fort Myers, FL
Position: Loan Officer
Start Date: 8/25/98; End Date: 6/3/04; Schedule: Full-time
Length: Almost 6 years; Wage: Commission $65,000 in 2001
Duties: Originate and process loans.
Reason for Leaving: Terminated
Employer: Burdines; City/State: Fort Myers, FL
Start Date: 9/1987; End Date: 9/2001; Schedule: Full-time
Length: 14 years; Wage: Commission: $35,000
Duties: Selling major appliances
Reason for Leaving: Mortgage business was becoming successful.
Employer: Carriage House - High Rise Luxury Apt. Building;
City/State: Aventura, FL
Start Date: 6/1983; End Date: 6/1987; Schedule: Full-time; $300/week + apartment
Duties: Director of Guest Relations
Reason for Leaving: Moved to Cape Coral.
A time-line was created to more carefully outline the events:
8/25/98 : Began working at First United – Territory: Cape Coral to Naples.
9/8/02 : Date of Accident
9/2003 : Returned to work w/First United, six hours per day – Limited to working the market in her home area as she could not travel.
9/2003-1/2004 : Took this long to reconnect with customers & start bringing in new business.
1/2004 – 6/2004 – Continued to work for First United – six hours per day. (@ First United, she had a home office, so she could still work from home if she did not feel well).
6/3/04 : Terminated from First United
6/4/04 : Began working at Brooms – tried to work full time, but only managed 6 hours per day.
(@ First United, she had a home office, so she could still work from home if she did not feel well. At Brooms she had to go into the office each day).
8/13/04 : Hurricane Charley hits west coast of Florida – destroys Brooms Mortgage building and a large part of Ms. Drawdy’s house.
Mortgage industry in that area took a huge hit. Ms. Drawdy indicated that had she not been injured, she would have relocated to Tampa, Orlando or Ft. Lauderdale as the industry was still doing well in those areas.
Currently has a Loan Officer’s License. If she had a Broker’s License, she feels she could do better, not having to get a quota of loans and able to contract her own cases.
To get a Broker’s License:
- Must complete 24 hours of classroom education on primary and subordinate financing transactions and the mortgage laws and rules.
- Exam offered on the 4 th Tuesday (or Wednesday) of each month.
- All applicants must obtain and complete an application for the license prior to sitting for the state exam.
- A 24-Hour Mortgage Broker pre-license course covers all materials required by the state. ($249)
- An intensive one-day cram course is offered to help prepare for the Licensure. ($75).
- Mortgage Class Interactive CD-ROM for study: ($50).
- Mortgage Loan Processing Study: $399; 3 days.
- Exam: Application Fee of $200; Fingerprint Processing: $15; Licensing good for only two years before continuing education must be submitted.
Orientation: Alert and Oriented x’s three.
Stream of Thought: Clear and Rational.
Approach Toward Evaluation: Positive.
Appearance: Overtly disabled.
As part of this evaluation, Gwendolyn is asked to complete the Wahler Physical Symptoms Inventory; theBeck Depression Inventory; the Beck Anxiety Index; the Beck Hopelessness Scale; the Beck Scale for Suicidal Ideation; and the Minnesota Multiphasic Personality Inventory-2, (MMPI-2).
On the Wahler Physical Symptoms Inventory, her score of 3.50 places her in the 99 th percentile regardless of the criterion group used for comparison purposes. She demonstrates an elevated somatic focus with evidence of an underlying hysterical/anxiety component resulting from long term exposure to severe disability as well as pain.
On the Beck Depression Inventory her score of 33 suggests a severely elevated clinical depression. This is consistent with the results of the clinical interview and her MMPI-2 depression scale. The combination of test results and clinical interview meet the criteria within the DSM-IV-TR for a diagnosis of Major Depressive Disorder-Single Episode-Moderate.
On the Beck Anxiety Index her score of 31 does indicate a clinically significant level of anxiety. This is consistent with findings on her MMPI-2. The MMPI-2 is a more sensitive and broad based personality scale allowing for an exploration of traits beyond those examined on the Beck. As far as the Beck goes the MMPI-2 is in concurrence. The combination of test results and clinical interview meet the criteria within the DSM-IV-TR for a diagnosis of Generalized Anxiety Disorder.
On the Beck Hopelessness Survey her score of 14 suggests a pessimistic outlook on her future. Research indicates the Hopelessness Scale is far more predictive of Suicidal Tendencies in the future than the results of the depression scale and must be used in conjunction with Clinical Interview for more accurate results. Her results on this scale are also consistent with her MMPI-2 results. Based on my clinical interview and overall test interpretation she demonstrates depression, generalized anxiety with evidence also of physiologic anxiety, a focus on her disability and loss of self-esteem. I do not find evidence of suicidal ideation.
On the MMPI-2 a valid profile is obtained based on a review of the validity scales. Consideration is first given to the VRIN, (variable response inconsistency), and TRIN, (true response inconsistency), subscales which used paired responses of similar and opposite items to measure inconsistencies in response patterns. An inconsistent response pattern represented by significantly elevated T-scores invalidates the profile. In Gwendolyn’s case the T-scores are within normal limits. Next, I evaluated the F, F sub b and sub p scales which represent infrequently endorsed items that are sensitive to random and fixed responding. Again, significantly elevated T-scores will invalidate the MMPI-2 results. Gwendolyn’s T-scores are within normal limits.
Finally, I reviewed the L, K and S scales. In this instance T-scores greater than 79 on the L scale, 75 on the K scale and 70 on the S scale tend to reflect individuals who are demonstrating protocols characterized by a pervasive pattern of nonacquiescence. This is a pattern often referred to as a “fake good” profile. The individual is trying to present a better picture of themselves than actually exists. Gwendolyn’s scores do not exceed these parameters and therefore her MMPI-2 is considered valid. There is no evidence of impression management and no indication of either “fake good” or “fake bad” profiles. She shows no indication of malingering in her clinical scales.
On the clinical scales Gwendolyn demonstrates an elevated triad profile with hysterical/anxiety reaction, (scale three) at the peak followed by a severely elevated scale two, (depression). This is followed by a clinically elevated scale one, (somatic focus). This profile represents a classic chronic disability/chronic pain profile consistent with exposure to severe disability and pain over time. She is also at or exceeds clinical significance on scales six, seven and eight, (paranoia, psychasthenia and schizophrenia). At these elevations this profile suggests feelings of inadequacy, inferiority, lowered self-esteem, poor self-concept a lack of self-confidence and paranoia. The profile also reveals anxiety, guardedness, anger and resentment over her situation and feelings of depression, sadness and withdrawal.
Coupled with clinical interview her testing suggests depression, generalized anxiety disorder and a chronic disability/chronic pain disorder.
Major Depressive Disorder-single episode-moderate
Generalized Anxiety Disorder
Adjustment Disorder secondary to disability and medical condition.
Chronic pain/Chronic Disability Disorder secondary to disability and medical condition.
MRI of the thoracic spine revealed minimal endplate spur and disc bulge at the T3-4 and T4-5 levels.
Gastroesophageal reflux disease
S/P Surgical Cervical fusion changes at the C6-7 level anteriorly and posteriorly.
Signal alteration involving the C6-7 disc interspace. It was possibly related to above/metallic artifact; however, low grade infectious etiology could give that presentation.
Spurring and concentric disc bulging at C5-6 with moderate facet arthropathy. It flattened the thecal sac and there was borderline canal stenosis and foraminal narrowing. Both C6 nerves appeared abutted.
Possibility of progressive degeneration at the C5-6 level, and eventually she may require surgical intervention in that area.
Life Stressors secondary to disability and psychological response to exposure to disability.
Careful consideration has been given to all of the medical, psychosocial, and rehabilitation/mental health counseling data contained within this file and my report. Gwendolyn remains with significant vocational handicaps and physical restrictions/limitations secondary to the 9/8/02 onset of disability.
The Rehabilitation Plan and recommendations, a part of the Vocational Worksheet, outlines all of her needs dictated by the onset of disability throughout her life expectancy. Recommendations are made within the context of the Vocational Worksheet to maximize her options post injury, and to try to return her to as functional a level as possible, in view of her physical status and chronic pain complaints. This will include a recommendation for a Chronic Pain Treatment Program. Her current status for work is significantly hampered by the following:
- Her degree of pain,
- Her physician's indication that she is a potential candidate for further surgery,
- The degree of limitations stemming from the combination of subjective complaints and objective medical findings, and
- Her poor candidacy for moving into the rehabilitation recommendations until surgical options have been completed or eliminated.
The role of psychological factors in chronic pain is quite complex. Chronic pain constitutes a complex mixture of pathophysiologic factors interacting with numerous psychological, social and cultural factors, including the following:
- Depression, anxiety and personality disorders
- Defective coping styles
- Autonomic stress reactions
- Lifestyle factors
- Noncompliance with treatment program
- Disturbances of interpersonal relationships
- Appraisal of stressful events
- Beliefs about control of pain
- Self-efficacy and cognitive distortions
- Involvement with disability or worker’s compensation programs
A comprehensive chronic pain treatment model includes the clinical health psychologist consulting with the patient, family and treatment team. The target of intervention is the interaction of psychological and physiologic factors that cause and perpetuate chronic pain. Patients with complex chronic pain present with multiple risk factors for poor outcomes, however. Psychological factors are usually significant and numerous in patients with complex chronic pain, and may exhibit depression, anxiety or personality disorders than can interfere with treatment if not addressed. In some, the underlying pathophysiologic state may be exacerbated by emotional distress, which presents as intensified pain symptoms.
The Vocational Worksheet also outlines Gwendolyn's capacity to earn pre-injury as compared to her capacity to earn post-injury, along with related vocational issues.
After you have had an opportunity to review this narrative report and the attached appendix, please do not hesitate to contact me should you have further questions.
Paul M. Deutsch, Ph.D., CRC, CCM, CLCP, FIALCP
Licensed Mental Health Counselor, (FL MH#0000117)
PAUL M. DEUTSCH & ASSOCIATES, P.A.
ATTACHMENT: Appendix A - Vocational Worksheet
Source: Why is chronic pain so difficult to treat? Psychological considerations from simple to complex care. Mark B. Weisberg, Ph.D., Alfred L. Clavel, Jr., MD. Chronic Pain, Vol. 106, No. 6, November 1999, Postgraduate Medicine.