Formal Pain Evaluation Report

(Based on the AMA guides 5th edition)

Patient: Date of Birth: Social Security Number: Date of Injury or Illness: Consult Date: Treating Physician:

Violeta Solis 05/02/58 594-40-3679 12/30/11 01/12/12 Kristy Tran

INTRODUCTION Chapters 3 through 17 of The Guides to the Evaluation of Permanent Impairment 5 th Edition provide the framework for determining the Organ and Body System Specific Impairment Rating of the injured patient. The physician assigning the rating must determine whether the amount and character of the pain that the patient experiences (if any) is adequately reflected in the assigned organ and body system rating. If, in the assessing physicians opinion, pain is not adequately reflected in the rating, up to an additional 3% may be added to the impairment rating. In addition, the physician can determine whether a formal pain assessment should be performed according the criteria described in Chapter 18 (pages 565 591) of The Guides. A formal pain assessment should be performed if any of following situations is present: When There is Excess Pain in the Context of Verifiable Medical Conditions That Cause Pain (and have already been assigned an organ and body system impairment rating) When There Are Well-Established Pain Syndromes Without Significant, Identifiable Organ Dysfunction to Explain the Pain (Table 18-1, page 571) When There Are Other Associated (Non predictable) Pain Syndromes (Table 18-2, page 571) DATA The reason for conducting this formal pain evaluation on this patient is as follows: There is excess pain in the context of verifiable medical conditions that cause pain (and have already been assigned an organ and body system impairment) The formal pain assessment consisted of the following steps:

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Violeta Solis

Formal Pain Evaluation Report

(Based on the AMA guides 5th edition)

1. Completion of a pain questionnaire (Table 18-4,page 576-577) by the patient with information regarding severity of pain, activities of daily living (ADL) restrictions, and emotional distress 2. Observation by the examiner of the patients pain behaviors (Table 18-5, page 580) 3. Determination by the examiner of the patients credibility 4. Calculation of a Total Pain-Related Impairment Score using the criteria described in Table 18-6 (page 584) 5. Determination of Pain Impairment Class Step 1: Patient Questionnaire The patient provided the following responses to the questions of Table 18-4 of The Guides: Section I (Pain: Self Report of Severity) Question A. Rate how severe your pain is right now, at this moment B. Rate how severe your pain is at its worst C. Rate how severe your pain is on the average D. Rate how much your pain is aggravated by activity E. Rate how frequently you experience pain Range No pain (0) Most severe pain can imagine (10) None (0) Excruciating (10) None (0) Excruciating (10) Activity does not aggravate pain (0) Excruciating following any activity (10) Rarely (0) All of time (10) Response 9 10 9 7 7

Sum of Section I: A D = Total pain severity Total pain severity/4 Sum of (Total pain severity score/4) and Question E Section II (Activity Limitation or Interference) Question A. How much does your pain interfere with your ability to walk 1 block? B. How much does your pain prevent you from lifting 10 pounds (a bag of groceries)? C. How much does your pain interfere with your ability to sit for hour? D. How much does your pain interfere Range Does not restrict ability to walk (0) Pain makes it impossible for me to walk (10) Does not prevent from lifting 10 pounds (0) Impossible to lift 10 pounds (10) Does not restrict ability (0) Impossible to sit for hour Pain does not interfere (0)
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35 8.75 15.75

Response 6 0 0 6

Violeta Solis

Formal Pain Evaluation Report

(Based on the AMA guides 5th edition)

with your ability to stand for hour? E. How much does your pain interfere with your ability to get enough sleep? F. How much does your pain interfere with your ability to participate in social activities? G. How much does your pain interfere with your ability to travel up to 1 hour by car? H. In general, how much does your pain interfere with your daily activities? I. How much do you limit your activities to prevent your pain from getting worse? J. How much does your pain interfere wit your relationship with your family/partner/significant others? K. How much does your pain interfere with your ability to do jobs around your home? L. How much does your pain interfere with your ability to shower or bathe without help from someone else? M. How much does your pain interfere with your ability to write or type? N. How much does your pain interfere with your ability to dress yourself? O. How much does your pain interfere with your ability to engage in sexual activities? P. How much does your pain interfere with your ability to concentrate?

Unable to stand at all (10) Does not prevent me from sleeping (0) Impossible to sleep (10) Does not interfere with social activities (0) Completely interferes with social activities (10) Does not interfere (0) Completely unable to travel 1 hour by car (10) Does not interfere (0) Completely interferes (10) Does not limit activities (0) Completely limits activities (10) Does not interfere (0) Completely interferes (10) Does not interfere (0) Completely unable to do any job (10) Does not interfere (0) My pain makes it impossible to shower or bathe without help Does not interfere (0) My pain makes it impossible to write or type (10) Does not interfere (0) My pain makes it impossible to dress myself (10) Does not interfere (0) My pain makes it almost impossible to engage in any sexual activity (10) Never (0) All the time (10)

9 7 0 7 7 7 6 6 6 6 7 9

Sum of Section II: A P (Total score for activity limitations) Total score for activity limitations/16 = Mean activity limitation Section III (Individuals Report of Effect on Mood) Question A. Rate your overall mood during the past week
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89 5.5625

Range Extremely high/good (0)

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Formal Pain Evaluation Report

(Based on the AMA guides 5th edition)

B. During the past week, how anxious or worried have you been because of your pain? C. During the past week, how depressed have you been because of your pain? D. During the past week, how irritable have you been because of your pain? E. In general, how anxious/worried are you about performing activities because they might make your pain/symptoms worse?

Extremely low/bad (10) Not at all anxious/worried (0) Extremely anxious/worried (10) Not at all depressed (0) Extremely depressed (10) Not at all irritable (0) Extremely irritable (10) Not at all anxious/worried (0) Extremely anxious/worried (10)

9 9 9 9

Sum of Section III: A E = Total pain impairment attributed to mood state Total pain impairment attributed to mood state /5 (Mean Score) Step 2: Patient Pain Behaviors During the formal pain assessment, the examiner observed the patient exhibit the following observable pain behaviors: Facial Grimacing Sitting With a Rigid Posture Moving in a Guarded or Protective Fashion Moaning

45 9

Based on the above mentioned observable pain behaviors and knowledge of the individuals diagnosis and organ dysfunction, a global pain behavior score is assessed using the criteria in Table 18-5(page 580): Pain behavior Exaggerated and non physiologic Mixed or ambiguous Appropriate and tends to confirm other clinical findings Behavior score -10 0 +10

In this patient, the global pain behavior score is 7.

Step 3: Assessment of Patients Credibility Assessment of the patients credibility consists of determining:
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Formal Pain Evaluation Report

(Based on the AMA guides 5th edition)

Congruence with established conditions Consistency over time and situation Consistency with anatomy and physiology Observer agreement Other inappropriate illness behavior

Assessment of credibility is a qualitative process by the examiner. A score is assigned ranging from -10 (low credibility) to +10 (high credibility). In this patient, the examiners assessment of the patients credibility is 7. Step 4: Calculation of Total Pain Related Impairment Score The final Total Pain-Related Impairment Score is calculated using Table18-6 (page 584): Assessment Step 1: Table 18-4, Section I score Step 1: Table 18-4, Section II score times 3 Step 1: Table 18-4, Section III score Step 2: Table 18-5, Global Pain Behavior Rating Subtotal Step 3: Credibility score Total Pain Related Impairment Score Table 18-7. Determining Impairment Class No significant impairment Mild Impairment Moderate Impairment Moderately Severe impairment Severe Impairment SUMMARY Maximum score 20 30 10 10 70 10 80 Patients score 15.75 16.6875 9 7 48.4375 7 55.4375 Impairment score 0-6 7-24 25-42 43-60 61-80

Step 5: Determination of Pain Impairment Class

According to Table 18-7 (page 584), with a Total Pain-Related Impairment Score of 55.4375, this patient has a pain related impairment class of Moderately Severe Impairment
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Violeta Solis

Formal Pain Evaluation Report

(Based on the AMA guides 5th edition)

AMA Guide Page 573 If the examiner performs a formal pain-related impairment rating, he or she may increase the percentage found in step A (Evaluate the individual according to the body or organ rating system, and determine an impairment percentage) by up to 3%, and he or she should classify the individuals pain related impairment into one of four categories: mild, moderate, moderately severe, or severe..

Based on the Total Pain Related Impairment Score above, the patient qualifies for a 3% WPI for Pain.

In compliance with recent worker?s compensation legislation (Labor Code 4628 (j) and 5703 (a) and insurance code 536) I declare under the penalty of perjury that I have not violated the Labor Code section 139.3 and that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief except as to information that I have indicated that I received from others. As to that information, I declare under the penalty of perjury that the information provided to me accurately describes the information provided to me except as noted herein. I believe this to be true. Furthermore, this evaluation is in compliance with the guidelines established by the Industrial Medical Council or Administrative Director pursuant to paragraph (5) of subdivision (j) of Labor code section 139.3 and 5307.6.

Approved and electronically signed by me in the County of Orange on the approval date below.

_____________________________

Sana U. Khan, MD. Ph.D. Neurophysiologist

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