Kim Olden, ALHCACS Disability Claim Consultant

EARL J. FLEEGLER, M.D., P.C. SURGERY OF THE HAND THE PAVILION 261 OLD YORK ROAD, SUITE 505 JENKINTOWN, PA 19046 PHONE (215) 572-6363 FAX (215) 572-6344

January 26, 2005

Kim Olden, ALHCACS Disability Claim Consultant Disability Management Services, Inc. One Park Place, 300 S. State Street, Suite 250 Syracuse, NY 13202

RE: JACQUELINE DI STEFANO Policy Numbers: 92X1-15-12 and 88X2-96-73

Dear Ms. Olden:

Thank you for the referral for independent medical evaluation of Ms. Jacqueline DiStefano who was seen today, January 26, 2005. The patient identified herself by means of a Pennsylvania driver’s license; she is fifty-seven years old and right-handed. Her previous work was that of a dental hygienist that she explains she stopped in January 2004.

The patient’s history reveals that her chief complaints include:

1. Severe pain, up to ten out of ten on the zero to ten pain scale, where zero is no pain and ten the worst pain in her life when touching her right index and middle fingertips.

2. She has numbness in the right index and middle fingertips all the time that she explains has been present since her surgery of April 1, 2004.

3. “The screws make me feel like my nerves are hanging out.”

History of present illness was obtained from the patient and the records that you were kind enough to furnish, which were reviewed. You had asked about time spent on review of this patient. The record review time is approximately one hundred and ninety minutes. One and a half-hours were spent on the history and physical examination and additional time has been spent on this dictation and will be spent in its review. The patient’s history of present illness reveals that she had been having pain, especially in her right index and middle fingers, as well as thumb, for five or six years. This pain was exacerbated by such activities as squeezing the alligator clip putting on patient’s bibs in her work as a dental hygienist. Writing to document the health histories was also painful and she pointed out the right thumb interphalangeal joint and distal joints of her right index and middle fingers with regard to this pain. Dental hygienist activities, such as scaling teeth with sharp instruments, placing x-ray films and taking x-rays, also produced pain in the above-mentioned areas, which pain was sharp when the activity was carried out, continued as an achy pain, and occasionally was associated with tingling in all of the digits of her hand (right). She explains that at one point she was awakening every night with tingling and that splints that were recommended (please see her records, including Dr. Andrew Mermelstein’s reports, and those reports from Dr. Randall Culp. Also note the records from her family January 26, 2005 RE: Jacqueline DiStefano Page 2 physician, Dr. Andrew Ecker. The splints helped somewhat, although at times she felt claustrophobic in them and took them off. Other activities that produced some relief were applying pressure to her hands. She also complains of changes compatible with Raynaud’s phenomenon, including white discoloration of her fingers. Other activities at work during that period that were difficult included polishing teeth and probing pocket depth. She continued to attempt to work, which she explains she liked very much, although “it was killing my fingers.” The pain, according to the patient, was most severe over the last five years.

Physicians that she saw for help included Dr. Ecker and Dr. Mermelstein, as well as the hand surgeon, Dr. Culp at the Philadelphia Hand Center. Splints and anti-inflammatory medications were utilized for treatment.

After having previously reviewed the alternatives of treatment with the patient, Dr. Culp operated upon her April 1, 2004 and carried out arthrodeses of her right index and middle finger distal joints utilizing what sounds like Herbert screws for internal fixation and these screws remain in place. The patient explains that some of the DIP joint, right index, and middle finger pain present before the surgery has improved, but that tips of the fingers are left in a painful condition and she is unable to bend these last, or distal, joints.

Now, she has difficulties with many of the activities of daily living, as well as being unable to do her work as a dental hygienist secondary to the pain in the right index and middle fingertips and the loss of dexterity. She feels that two patients were injured because of her working on them with these disabilities. I also note that she has stopped activities that she enjoyed, such as racquetball, because of her right hand pain, cannot use a computer or type because of this pain, and finds that it is not possible for her to substitute her left hand for these activities with reasonable ability to carry them out.

At my request, a “FCE” report carried out by Kristie McIntyre, OTR/L, assessment specialist, was faxed to me today. It is not completely clear in my reading of this report just what the patient’s functional capacity is at this time. I note that in the report dated January 14, 2005 this is described as “a valid representation of the present physical capabilities of Jacqueline S. DiStefano, based upon consistencies and inconsistencies when interfacing grip dynamometer graphing, resistance dynamometer graphing, heart rate variations, weights achieved, and selectivity of pain reports and pain behaviors. The client is demonstrating full effort.” At the start of that assessment, Ms. McIntyre points out that the patient already had a pain level in the right hand of seven out of ten and at termination of the assessment, approximately fifteen minutes after it was finished, the pain level was reported as ten out of ten. Reference was made to spasms and white color change in the patient’s fingers, as well. Ms. McIntyre pointed out that Ms. DiStefano “did not demonstrate the ability to meet the following job requirements; a work day of eleven to twelve hours, standing for the majority of the work day with forty-five minute durations, continuous hand use and continuous reaching.” If this is the conclusion from the testing carried out, with regard to the patient’s hand problems, it is consistent with my findings.

Past history revealed that the patient is not allergic to any medications. She is on hormone replacement therapy, as well as Fosamax and multivitamins and was not certain with regard to the current medication she is receiving from Dr. Mermelstein, but in his report of February 26, 2004 that appears to be Diclofenac 75 mg by mouth with food twice a day. January 26, 2005 RE: Jacqueline DiStefano Page 3

Additional history, including social history, family history, and review of systems was obtained, should you need this. It is pertinent that the patient also has approximately five or so year history of Raynaud’s phenomenon, involving not only her hands, but also her feet.

Examination revealed a 57-year-old woman who did not appear to be in acute distress, although seemed somewhat anxious, and she was cooperative for this examination. I noted when handing her the x-rays back, for example, that she used her left hand mostly in placing these in the bag that she had brought for them. The x-rays available were from May 18, 2004, therefore, postoperative, showing what appeared to be Herbert screws in the right index and middle fingers distal phalanges, and across the distal joints into the middle phalanges. The distal joint spaces do appear to be gone, which would be compatible with arthrodeses, although the x-rays are somewhat dark and not as clear as I would like them to be. She appeared to have some osteoarthritic change involving the right thumb, scapho-trapezial joint, as well.

Neck movements revealed that turning to the left, which was decreased, produced right neck pain. She sits with her occiput slightly tilted toward the left. Bending and turning her neck were decreased bilaterally. Extension was carried out relatively well and flexion of her chin was possible to about 1.5 cm from her chest. These movements did not produce any upper extremity dysesthesias.

Shoulder abduction, retroposition, and depression were negative for tingling and carried out well.

Elbow flexion test was negative and flexion to extension range of motion full bilaterally.

Phalen’s test at this time is negative bilaterally, although I note in the record review that Dr. Culp had found it positive on at least one occasion.

Wrist flexion on the right is to 60 with some circumferential wrist achiness and on the left to 57. Wrist extension is 66 bilaterally.

Tinel’s sign is positive over the right carpal tunnel to the index and middle fingers and negative over the left carpal tunnel. It is negative over the ulnar tunnels bilaterally.

Opposition of her thumbs is good at 5/5 bilaterally.

First dorsal interosseous function 5/5 bilaterally.

Vascular examination revealed the radial pulses to be +1 – 2 and the ulnars +1 bilaterally. I do note that the skin and nailbed areas of her fingers, especially in the nail areas, appear somewhat more orange-red in color than I think would be normal.

Evaluation of finger range of motion reveals that her right index and middle fingers lack 3.5 cm from the tips touching the distal palmar crease, whereas the right ring just about touches and the little does touch. On extension, the right middle distal joint lacks 24 and the right index 10 January 26, 2005 RE: Jacqueline DiStefano Page 4 from full extension and the left index also lacks 11 of full extension. On flexion, the right index finger tends to cross somewhat into the middle finger.

Index and middle finger range of motion:

Index Finger Right Left MP Joint: +25/80 +25/65 PIP Joint: 0/93 0/103 DIP Joint: Essentially fixed at -10/66 about –10

Middle Finger Right Left MP Joint: +26/84 +25/85 PIP Joint: +10/92 0/102 DIP Joint: -21 approximately 0/71 fixed

Gently touching the very tips of the fingers with the Semmes-Weinstein monofilament rated at decreased light touch, or 3.61, produced an uncomfortable tingling or dysesthesia of the index and middle fingers.

Sensory evaluation by Semmes-Weinstein monofilaments over the volar aspects of the fingers and thumbs reveals that the right thumb is decreased light touch, the index decreased light touch, and middle decreased light touch, whereas the right ring is normal (2.83) and the little decreased light touch. The left thumb ranges from just about normal to decreased light touch, the index decreased light touch, the middle just about normal to decreased light touch, the ring normal, and the little from just about normal to decreased light touch.

Grip strength testing by the Jamar dynamometer reveals:

Right Left I 19.5 lbs 21 lbs III 29 lbs 30 lbs IV 20.5 lbs 24 lbs *

* (Note that one would expect a somewhere between 10 – 20% greater finding in the dominant right hand)

Pinch strength testing revealed:

Right Left Tip pinch: 3 lbs and then patient complained 5 lbs of discomfort Key pinch: 8 lbs 8 lbs Three jaw 3.5 lbs 7 lbs chuck: January 26, 2005 RE: Jacqueline DiStefano Page 5

Finkelstein test was negative bilaterally.

Grind test was positive bilaterally.

In addition, evaluation revealed that there is a “HH”-shaped scar present over the dorsum of the right index and middle finger distal joint areas and these scars were not particularly tender to light touch.

Impression:

1. Pain right index and middle fingertips with tenderness as described above. 2. Raynaud’s phenomenon, as described. 3. Probable right carpal tunnel syndrome. 4. Osteoarthritis involving multiple areas as described above.

Discussion:

My impression of this patient is that she was cooperative for the history and examination and appeared to be reliable with findings that were consistent with the records reviewed. In my opinion, the findings with regard to her right hand, and especially her index and middle fingers in this right-handed woman, make her totally disabled from her usual work. In your letter to me, you questioned whether I could recommend things that might be helpful to her. It is possible that if the Herbert screws could be removed from her fingers and if the arthrodeses hold up well, that a significant part of her pain would be relieved. I would have to defer to Dr. Culp to see if he can carry this out. However, this would still leave her with the stiffness described. My own approach to that, when the pain improved, if it did, would be to recommend a hand therapy reeducation and work hardening program to see if she would be able to, at least part-time, resume her work as a dental hygienist. If the above is not possible, then I don’t see where any other therapy to her hands will change the patient’s discomfort.

Thank you for the opportunity to participate in this IME. I had explained to the patient prior to starting it that I was not becoming her physician. Please do let me know if there are any questions with regard to this.

Sincerely,

Earl J. Fleegler, M.D.

EJF/kel 06-00520491.doc