Malden Retirement System
Town Hall
110 Main Street
Malden, U.S.A.
Gentlemen:
I examined the above-named claimant at your request in my
office on 3/11/96. A history was obtained that on September
4, 1995, while occupied as a parole officer in her office,
she fell off a chair onto her back. She indicated she
received treatment from Dr. Singh, her primary care provider,
who referred her to Dr. Morrison, an orthopedic surgeon. She
sees the orthopedist once monthly and also Dr. Singh once
monthly. They are awaiting authorization from Workers'
Compensation to have her acquire a TENS unit.
She received physical therapy twice weekly for a four-month
period and now receives it on a once a week basis. There
were no medical reports available for review, other than what
was offered to me by the claimant, which was a report of an
MRI of the lumbar spine taken on September 4, 1995. The
impression was multi-level disc dessication and annular
bulging with superimposed anterior disc herniation L5-S1. A
focally herniated disc fragment, or canal stenosis, was not
seen.
Complaints offered at the time of my examination were pain
in her lower back with numbness in the left calf. She does
have occasional good days, but depends on the position she
sleeps in. She indicated a definite tightness on this day of
examination.
Past history indicates an arthrotomy of the right knee in
1984, a contusion during an assault to her left leg,
resulting in pulmonary embolism in 1987. She was out of work
for one year. She fractured her thumb in 1991. In November
of 1994, she had similar complaints regarding a pulmonary
embolism, but the tests were normal. She has not returned to
work since the injury of September 4, 1995.
Physical examination revealed a well-developed,
well-nourished, 45-year-old female, who stands 5'5" tall and
weighs 145 lbs. She was observed to have a normal gait and
station. She appeared to move freely and continued to utter
complaints of her low back pain. Examination of the spine
revealed the shoulders and pelvis to be level and the spine
straight. She pointed to her lower lumbar segments as to the
area of discomfort. She indicated discomfort on extension,
lateral tilt and rotation of the trunk on the pelvis and
forward flexion. She flexed until her fingertips reached the
floor level. There was no evidence of muscle guarding in the
form of spasm during her range of motion. She has good
gluteal tone. She could heel and toe raise.
Both sitting and supine flexion, straight leg raising and
Laseque tests were within normal limits. She had full range
of hip, knee, ankle and foot motion. There was no atrophy of
disuse of the lower extremities. There was noted a fullness
of the right knee without heat.