E ARL 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:
Policy Numbers:
JACQUELINE DI STEFANO
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
physician, Dr. Andrew Ecker. The splints helped somewhat, although at times she felt
January 26, 2005
Page 2
RE: Jacqueline DiStefano
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
Page 3
RE: Jacqueline DiStefano
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
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.
January 26, 2005
Page 4
RE: Jacqueline DiStefano
Index and middle finger range of motion:
Index Finger
MP Joint:
PIP Joint:
DIP Joint:
Right
+25/80
0/93
Essentially fixed at
about –10
Left
+25/65
0/103
-10/66
Middle Finger
MP Joint:
PIP Joint:
DIP Joint:
Right
+26/84
+10/92
-21 approximately
fixed
Left
+25/85
0/102
0/71
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
19.5 lbs
29 lbs
20.5 lbs
I
III
IV
Left
21 lbs
30 lbs
24 lbs *
* (Note that one would expect a somewhere between 10 – 20% greater finding in the dominant
right hand)
Pinch strength testing revealed:
Tip pinch:
Key pinch:
Three jaw
chuck:
Right
3 lbs and then patient complained
of discomfort
8 lbs
3.5 lbs
Finkelstein test was negative bilaterally.
Left
5 lbs
8 lbs
7 lbs
January 26, 2005
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RE: Jacqueline DiStefano
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.
2.
3.
4.
Pain right index and middle fingertips with tenderness as described above.
Raynaud’s phenomenon, as described.
Probable right carpal tunnel syndrome.
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