Medical History

• What Is The Difference Between Exacerbation and Aggravation?

  01 March 2012 / Impairment Physical Exam, Medical History / 0 Comment

  A CASE STUDY FOR LEARNING.

  A 28 year old man injured his low back at work while doing repeated bending and lifting. He had a well documented pre-existing low back pain history with lumbar spine imaging that showed moderate to severe degenerative changes.

  His base line back pain was 2/10 and occasional. His work injury increased his symptoms to 8/10 and constant. The claim was accepted.

  Treatment consisted of anti-inflammatory medication and therapy. Repeat imaging confirmed his degenerative pre-existing low back pain condition.

  He was found to be a non surgical candidate. He was referred for impairment rating with the claim being nearly three years old at referral. He remained on light duty these entire three years.

  At impairment rating, he was obese, and his lumbar spine exam demonstrated no ratable findings (i.e. WPI =0%). It was discussed and agreed upon that the employee would perform a trial of full duty, although his pain was still above his pre-injury baseline.

  The employee was opined to be at maximal medical improvement (MMI). He was provided a provisional opinion that his pre-existing low back condition had been “aggravated” on an industrial basis. Future care was outlined, and it was asked he follow up in three months for an update on his clinical status.

  At four months, the carrier provided additional prior chart documentation for review, which contained no new contributory information.

  A symptom review update was carried out the employee, and it was learned that he was tolerating work at full duty without problems, and his back pain had entirely returned to his pre-injury baseline without the need of increased supportive treatment (i.e. more pain medications or an “increased burden of treatment”).

  A summary supplemental report was issued which documented the return of the employee to his pre-injury baseline. The opinion of causation was revised based on new and additional information which found the employee’s back pain to now be best described as an “exacerbation”.

  No further future care was indicated, the impairment rating remained WPI =0%, and no further treatment on an industrial basis was recommended. The employee was discharged as cured.

   

  Discussion:

  There is often confusion about the terms “exacerbation” and “aggravation”. This case nicely demonstrates these “words of art” and how they apply to clinical situations.

  The claim had been appropriately managed with conservative care, and the employee was a non surgical candidate. He had become MMI. He had not, however, been returned to a trial of full duty.

  If this were the end of the story, his condition would be considered an industrial “aggravation” of his pre-existing low back pain.

  The AMA Guides 5th Edition, Glossary, page 599, defines an “aggravation” as, “A factor(s) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment”. More specifically, in clinical terms, a permanent “aggravation”.

  There was a clinical opportunity here, however, because the employee was very motivated to return to work. He was assured that after a thorough examination and review of his imaging studies, his pain was “not dangerous” and he should consider a trial of regular work, given that his current restrictions were based only on tolerance of symptoms, and not risk or capacity loss.

  He was furthermore reassured that if his symptoms worsened, he would simply return to clinic for replacement of his tolerance limitations. He agreed.

  The story ends happily, as the employee not only successfully returned to his usual and customary work, but the pain also returned to pre-injury baseline.

  An adequate trial of full duty for four months had been performed without “recurrence” of his low back symptoms. At this time, the opinion was revised to describe his condition as an “exacerbation” as that term is defined on Table 10-4, Chapter 10, Causation, of the AMA Disability, Second Edition, “Temporary worsening of a prior condition by an exposure/injury”.

   

  Keys of Review:
  • The AMA Guides 5th Edition, Glossary, page 599, defines an “aggravation” as, “A factor(s) that adversely alters the course or progression of the medical impairment. Worsening of a preexisting medical condition or impairment”.

  • This condition is best defined as an “exacerbation” as that term is defined on Table 10-4, Chapter 10, Causation, of the AMA Disability, Second Edition, “Temporary worsening of a prior condition by a exposure/injury”.

  • If the employee is motivated, and present restrictions are based only on tolerance, and not risk or capacity loss, consider a trial of full duty. Fear on behalf of the employee can be managed with adequate review of the physical exam findings and imaging if clinically appropriate. Agree on a clinical follow up plan to decide if future care management is still indicated in the claim, and further support your recommendations. This approach may minimize industrial morbidity and allow the employee to play a decisive role in the ultimate outcome of their injury.

• The Medical History: "Found Down, On Fire"

  01 December 2011 / Medical History / 0 Comment

  “Found down on Fire?!” I asked. “Really? That was it?!” I demanded.

  “Yes.”, answered The Captain, and he took another sip on his cocktail. He was calm and very comfortable in the San Diego evening. The tropical shirt on his chest was adjusted to allow more exposure to the sun as it went down over the Pacific. A small grin stole across his mustachioed face. I realized I was in the presence of a genius.

  The Captain, as I call him, is arguably the best trauma surgeon in Southern California. He had done his training at L.A. County Hospital. We had just finished a discussion on the best authored medical histories of our careers. Of course he had won…and knew it.

  This was several years ago now, but each time I set down to put pen on paper I think about the wisdom of this simple medical history that has withstood the test of time. In my opinion, “Found down on Fire” has no equal. It is a timeless classic in the “Medical History Hall of Fame” because it is the definition of simple and complete in its description. A little “too descriptive” according to some of my other colleagues, but no one has questioned it authority.

  I wanted to use this story to underscore the significance of being short and descriptive in the medical history component of the medical legal report. I think everyone can agree that it is much easier to write a long, rambling medical introduction and avoid the discipline and energy it takes to work with economy. If we were to open a medical chart on any teaching hospital service, you would find a five page note from the medical student, a one page note from the resident physician, and a one line note from the attending physician. Why? The attending physician understands the command of the language, and how to communicate the most information with the fewest words. Sound simple? Well, it isn’t. It is not until you have written pages and pages of histories that you are prepared and qualified to write a shorter, succinct history. Like anything else, it takes time to learn what is important in a history, and what is not.

  The medical history is where the whole thing starts…literally. The history is the reason that the claim is here in the first place. After years of reading, writing and thinking about the medical legal history, the best medical history is one that gives character and life to the description of the injury. The Captain impressed this upon me. To be a great history, the description of the injury must be accessible to all readers of the report, and leave no room for doubt as to the applicant’s description of the injury.

  Traditionally the doctor is taught to take the history in a standard, very predictable way. When did the symptoms start? What were you doing when the symptoms started? What makes the symptoms better? What makes the symptoms worse? What other symptoms do the primary symptoms cause? How often are the symptoms present? And this standardized approach definitely has its place. But what about this?

  How many reports have you read that began innocent enough, only to morph into a massive, confusing novel of epic proportions? A report that is well intended, can actually leave you frustrated and reaching for a bottle of aspirin by the fifth or twenty fifth paragraph? I have read a few of these. Actually, I have read more than a few of these.

  As a doctor writing a medical legal report, my goal is pretty clear: Does this story make any medical sense? Do I believe what I am writing? Can I explain myself to the claims adjuster or the attorney who is going to pick up and read this report? If it is clear and simple enough, I won’t have to do any explaining because the report will speak for itself. This is the goal!