CLAIM #: BD28377

YAKIMA MEDICAL CONSULTANTS, INC.

622 SOUTH 36th AVENUE
YAKIMA, WA 98902
(509) 966-9592 Fax (509) 966-8845

S. Daniel Seltzer, M.D., Medical Director Shirley Irwin, B.S.N., Executive Director
Diplomate American Board of Orthopaedic Surgeons Kris Nagle, Office Manager
Member of American Academy of Orthopaedic Surgeons
Licensed in States of Washington, Louisiana, and New Mexico
Member American College of Occupational and Environmental Medicine
Certified in Evaluations of Disability and Impairment Rating
 IDENTIFYING INFORMATION

Name: John Simpson Claim: BD28377

Address: 419 Victory Ln. Date of Injury: December 19, 2017
Yakima, Washington 98901-2156 Date of Birth: May 8, 1961

Employer at the time of injury: Huber Bros Rebar, Inc.

Date of Examination: December 20, 2018

Location of Examination: Yakima Medical Consultants, Inc.

Examiner: David U. Arango, M.D., Orthopedic Surgeon

INDEPENDENT MEDICAL EVALUATION

At your request, the above stated claimant underwent an Independent Medical Evaluation at
Yakima Medical Consultants, Inc. The claimant was examined by Dr. David Arango. The
examinee was informed as to the purpose of this evaluation and that it did not constitute a
general medical examination. By reading the information on the Permission To Be Examined
form, the claimant acknowledges a doctor-patient relationship has not been established, that this
evaluation is neither a substitute for receiving health care nor are the results of the evaluation to
be discussed.

The examinee was advised to report any type of discomfort that may be experienced during the
examination and not perform any motion, activity, or exercise that may be uncomfortable or
cause pain.

The dictated report is as follows:

HISTORY FROM THE WORKER:

CHIEF COMPLAINTS:

1. Burning on the dorsum aspect of the foot at night, difficulty sleeping.

2. Increased walking increases the pain, greater than two hours.

HISTORY OF PRESENT ILLNESS: This is a 57-year-old gentleman here today. He works

as a Steel Worker. The claimant states [05:28 unclear] about 2-foot deep hole which was lined
with a plastic. He was stepping out of a hole. It was raining that day. He sustained a slip and
fall. He did a splits and his left ankle snapped. He says that he drove him back self to Yakima.
There, he went to the emergency room and got x-rays. They told he had nondisplaced fibular
fracture. He was referred to Orthopedics. Orthopedics told him he needed to wear a boot and
put him in a fracture boot for approximately two months. He continued to follow with a doctor,
continued to complain of pain that when he had stiffness, he did not have much mobility and
secondarily, he complained of burning sensation on the dorsum aspect of his foot. He says this
went on for about five months.

He states he wanted the doctor to order an MRI; however, the doctor declined getting an MRI.

The claimant states he wanted to have another doctor who would listen to his complaints;
however, his treating doctor would not refer him out.

The claimant had to get his own doctor on his own for ongoing symptoms.

The new doctor started him on a course of physical therapy. He is currently in physical therapy.
He has been there for about four months.

CURRENT SYMPTOMS: He continues to complain of intermittent swelling to his ankle. He

complains of burning sensation on the dorsum aspect of his foot. He says he has burning at
night. It limits his sleeping. He says when he walks, his limit is about two hours and he need to
stop and rest for about 4 minutes because the pain becomes to a point that he is unable to walk.

He says he has intermittent episodes of swelling and says his symptoms never went away.

OCCUPATIONAL HISTORY: No previous trauma to his left ankle.

Current Work Status: Currently none. He is on unemployment. He also states that he is

working light duty. He says he drives a forklift. However, he is doing that on a full-time basis.

PAST HISTORY:

Illnesses: Hypertension.

Operations: None.

Allergies: None.
 Medications: None.

Substance Abuse: Currently, he is a smoker and he is a drinker.

SOCIOECONOMIC HISTORY: He is currently divorced. Two children. He enjoys fishing.

REVIEW OF SYSTEMS: No previous trauma to his left ankle.

CHART REVIEW: A review of the provided medical records is carried out and reveals the
following:

Claim Number: BD28377. Date of Injury: December 19, 2017. Accepted Conditions: Left
fibular fracture.

December 19, 2017. BD28377. Date of injury is December 19, 2017. Report of Accident. Box
19B. Stepping out of a hole and a leg went one way and the other went the other way.
Diagnosis: Left ankle nondisplaced fibular fracture.

December 19, 2017, x-rays, left ankle. Nondisplaced oblique fibular fracture.

December 21, 2017, hospital encounter. Provider: Dr. Greenwald. Work Injury: He was
stepping out of a hole and his leg slipped out from underneath him. He rates his pain 5/10. He
has constant sharp pain. He has swelling, bruising, limited range of motion. X-rays:
Nondisplaced lateral malleolus fracture. Plan: Using in a fracture boot, ice and elevation.

January 8, 2018, Dr. Greenwald follow-up. Closed fracture, lateral malleolus. His ankle is
swollen and tender. He has been doing some weightbearing. Plan. There is improvement in the
healing. No displacement of the fracture. X-ray shows interval healing of the fracture with an
early callus. There is no shifting of the mortise. Fracture is nondisplaced.

January 8, 2018, x-rays of the left ankle, oblique. Findings: Oblique longitudinal fracture, distal
fibula with soft tissue swelling.

January 29, 2018, Dr. Greenwald, follow-up for a left ankle fracture. His pain is 4/10 depending
on how much he is walking. Physical Examination: He still has burning in the ankle. He is
using the crutch and a fracture boot. Plan: X-rays showed good callus formation. No
displacement. Mortise is stable. He is going to wear regular shoe, discontinue using the crutch.

March 5, 2018, Dr. Greenwald, follow-up. He is using regular shoe, weightbearing without
crutches. He is in a Cam walker, using one crutch. Told him he needed to wear his fracture boot.
He was not wearing his fracture boot. He gets tired. Plan: He is making progress. Fracture is
healing. Increase activity.

April 9, 2018, follow-up. He presents for follow-up for his fracture. He is wearing normal
shoes. No crutches. He still has pain and swelling. He is wanting an MRI. He rates his pain at
about 2-6/10. Plan: The fracture is healing. He has good stability. I feel he can return to work.
I will see him in two weeks for closing of the case.
September 25, 2018, x-rays of his left ankle, Memorial Hospital. No visible fracture.
Degenerative changes of the tibiotalar joint.

September 28, 2018, Yakima Worker Care Clinic. Here for evaluation. Continued pain of the
left ankle. He sustained a fibular fracture. He was stepping on a wet plastic and he tripped and
broke his ankle. He has not returned to work since then. He reports pain dorsal to the foot. He
is not taking anything for pain. Plan: Repeat x-ray of the left ankle. Follow-up in two weeks.

October 16, 2016, Yakima Worker Care Clinic. Follow-up today for fibular fracture. X-ray was
discussed with the claimant. Reports pain to dorsum aspect of the foot. There is burning to the
dorsum of the foot when he starts ambulating. Refer to physical therapy, antiinflammatory,
follow-up in two weeks.

December 17, 2018, initial evaluation for physical therapy. Therapy continues on October 18,
2018, October 24, 2018, October 25, 2018, October 30, 2018, November 1, 2018, and November
5, 2018.

October 7, 2018, Yakima Worker Care Clinic, follow-up for left ankle injury. He is attaining
physical therapy. It is effective. He has one session remaining. He is scheduled for an IME. He
reports having some burning on the dorsum of the foot but not as much discomfort as before.

November 8, 2018, physical therapy.

IMAGING STUDIES: A review of the provided imaging studies is carried out by means of
review of the medical records.

PHYSICAL EXAMINATION: Height is 5 feet 11 inches. Weight is 205 pounds. He is

currently right-hand dominant.

Examination of his left ankle. He has pain over the lateral aspect of the anterior talofibular
ligament. There is direct pain on palpation of the ATFL.

Range of motion examination of his left ankle. Achilles tendon is intact posteriorly.

Examination of the left ankle, range of motion was measured today. Extension was to 15
degrees, flexion was to 60 degrees, inversion was 30 degrees, and eversion was 15 degrees. The
right ankle was also measured for symmetry.

The foot, he had normal ankle stability. He had no instability with internal or external rotation.
Arches were symmetric bilaterally. Achilles tendons were normal bilaterally. Lower extremity
circumferential measurements, calf, bimalleolar, and midtarsal were symmetric. They are in the
following table below:

ANKLES/SUBTALAR AND FOOT EXAMINATION

RIGHT LEFT
EXTENSION 15° 15°
 FLEXION 60° 60°
Inversion 30° 30°
SUBTALAR MOTION
Eversion 15° 15°
Calf 40 cm 40 cm
CIRCUMFERENCES Bimalleolar 26 cm 26 cm
Midtarsal 24 cm 24 cm
ANKLE STABILITY Normal Normal
ARCHES Normal Normal
ACHILLES Normal Normal
*Indicates pain

Lower extremity Achilles patellar reflexes are +2 and symmetric.

REFLEXES

RIGHT LEFT
KNEE 2+ 2+
ANKLE 2+ 2+
/absent tr (trace; +1 - +3 intensity) Aug.=Augmentation

He does have pain on palpation laterally over the ATFL. He describes the burning sensation at
the dorsum aspect of his foot. He has no pain behind the medial malleolus for the tendons. He
has no pain on palpation over the lateral malleolus for the peroneal tendons.

DIAGNOSES: Secondary to the claim of injury, the claimant's diagnoses are as follows:

ACCEPTED CONDITION: Left fibular fracture.

NEWLY CONTENDED CONDITIONS:

DIAGNOSIS AND ASSESSMENT OF WORK-RELATEDNESS:

Diagnosis: Left oblique nondisplaced fibular fracture.

Pre-existing Conditions: None.

Physical Restrictions: The patient states that he is currently on unemployment and he is also
working full-time 40 hours a week driving a forklift.

RECOMMENDATIONS:

Diagnostic Testing:
1. MRI of the left ankle without contrast.

2. X-rays of the left ankle, AP, lateral, and oblique view.

Therapeutic: Left ankle, he is currently in physical therapy program. At this point, he has
achieved full motion. He may continue on a self-directed home exercise program.

Follow-Up Care: Upon completion of the MRI of the left ankle, we will make the appropriate
recommendations if needed.

Findings Unrelated to the Accepted Conditions: None.

IMPAIRMENT REPORT:

MMI: Left ankle is not at MMI.

Physical Examination: Physical examination reveals that he has good range of motion but it is
a burning sensation that he has on the dorsum aspect of his foot. We are going to request an MRI
of his left ankle.

Diagnostic Tests: Recommending MRI of the left ankle.

Impairment Rating: The patient is not fixed and stable. Premature for impairment rating.

Rationale: The patient is still complaining of sensation of burning at the dorsum aspect of his
foot. He did have an ankle lateral malleolus fracture. He may have some undiagnosed
pathology. We are going to recommend an MRI of his left ankle in addition to an x-ray of his
left ankle.

CLAIM-SPECIFIC REQUESTS:

Sincerely,

David U. Arango, M.D.

DUA/etran/mpy/srt