Drafting

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July 31, 2025

Denise Almas

PO Box 4555

Portland, OR 97208

Re: Karie Kelly

Claim Number: SM18944

Date of Injury: 3/9/2021

Date of Birth: 5/2/1972

MCN Number: 20004776-1

Dear Denise Almas,

Thank you for allowing MCN to schedule an independent medical evaluation on Karie Kelly. The following is a report of the examination performed on 7/28/2025 in MCN Wenatchee. James Hazel, M.D., prepared and dictated this report.

The opinions expressed in this report are those of the provider, and do not reflect the opinions of MCN. The examinee was informed that this examination was at the request of Liberty Mutual Insurance - Portland, OR, that a written report would be sent to that agency, and that the examination was for evaluative purposes only. Furthermore, the examinee was informed that the purpose of the examination was to address specific injuries or conditions, as outlined by the requesting party, was not meant to constitute a general medical examination, and is not a substitute for seeking medical care from her personal provider. The examinee was also informed that during the examination she would not be required to engage in any physical maneuvers beyond what she could tolerate, or which she felt were beyond her limits, or could cause physical harm or injury.

The dictated report is as follows:

CHIEF COMPLAINTS

Her current complaints are low back pain up to the middle thoracic area. No radiating pain to the lower extremities but if she sits longer than an hour, she feels that her toes start to go numb. She states that she gets a clicking sensation that occurs deep in her ischial area and she points to the ischial tuberosity of both sides. Sometimes the clicking occurs on one side or the other. It tends to occur if she reaches forward. She thinks it is due mostly to extension of the hip. She describes it as "my sacral pops."

Claim Number: SM18944

Re: Karie Kelly

July 31, 2025 Page 2

HISTORY OF PRESENT INJURY

This is a 52-year-old female who sustained an industrial injury on March 9, 2021, while she was working for UPS as a driver/delivery individual. She had worked for UPS for about a year. Prior to working for UPS, she primarily performed retail logistics which is a desk job. On the date of the injury, she was trying to manhandle a package that was too heavy and hurt her lower back. She has not returned to work in that capacity since the industrial injury. She states that prior to that event, she had no prior history of back problems, no prior chiropractic treatment and there is no family history of back problems or any type of autoimmune disease. Her treatment consisted of physical therapy which did not really help and made her feel a little worse. She did not have any massage therapy. She did chiropractic with a provider who used a thumping machine and this did not help. Her second chiropractor that her partner had used got involved in her case and she received treatment for a couple of months with this chiropractic provider. She did report that she got temporary benefit and improvement in her pain levels. She has had no interventional injections. She has had MRI scanning demonstrating annular tears but no other significant abnormalities.

Overall, the claimant has not significantly changed in her course of complaints. She does not feel that she is significantly improved but does report that she is now at a point where things are

"tolerable" as long as she does not lift over 20 pounds or sit more than one hour. She is not currently receiving any medical treatment. She has gone through work hardening and work conditioning which actually made her feel worse and she has subsequently undergone vocational rehabilitation with training and she is now a certified engineer drafter. She is not able to find work because potential employers require two years of experience. CURRENT SYMPTOMS

She has low back pain and middle back pain without radiation to the lower extremities. The claimant's pain is much worse when she first wakes up. She wakes up and she states that she is "stiff as a board." By 10:00 or 11:00, she has limbered up to a better level. CHART REVIEW

Her medical record is reviewed. The medical record only consists of Independent Medical Examinations. The cover letter indicates that the accepted condition is lumbar sprain and the denied conditions are annular tear of the lumbar discs, intervertebral disc degeneration and left lumbar radiculitis.

An Independent Medical Examination was performed by Dr. Kitchel on August 23, 2021. He diagnoses lumbar sprain/strain and multilevel degenerative disc disease unrelated to the industrial injury of March 9, 2021, but temporarily aggravated. He recommended further physical therapy rehabilitation.

Claim Number: SM18944

Re: Karie Kelly

July 31, 2025 Page 3

There is an addendum report of November 8, 2021. It was noted that the claimant requires some level of work restrictions and he recommended a Physical Capacities Evaluation be performed. An Independent Medical Examination was performed on June 7, 2022, by Dr. Toomey. He diagnoses a lumbar sprain/strain. He reviews x-rays which are essentially negative except for some mild degenerative changes at the L2-L3 level and mild facet joint at L5-S1. He opines the claimant is at maximum medical improvement and should have a 40-pound lifting restriction. PAST MEDICAL HISTORY

Injuries: She does not report any previous surgeries. Illnesses: She does not report any previous serious medical problems. Allergies: None.

Medications: Ibuprofen and Tylenol.

FAMILY HISTORY

Diabetes but no autoimmune disease is known in the family. SOCIOECONOMIC HISTORY

Marital Status and Dependents: She is divorced with no dependents. Education: College.

Military: No armed services.

Brief Work History: She states that she has been employed for UPS for five years but on her history, she indicated that she only worked for UPS for approximately one year. Habits: She uses tobacco daily, less than a pack of cigarettes per day and she uses no alcohol. Physical Activity Level: She tries to walk every day for exercise. Time-Loss Compensation: She is receiving compensation benefits. PHYSICAL EXAMINATION

On physical examination, the claimant's height is 5 feet 1 inch. BMI appears to be approximately 25 to 27.

Her gait shows that she appears to walk with a slightly antalgic gait right and left more notable on the right than the left. She is able to walk on her heels and her toes. Claim Number: SM18944

Re: Karie Kelly

July 31, 2025 Page 4

Spine: She has no structural deformities. Limb lengths are symmetric. There is no kyphosis, lordosis or scoliosis.

Lumbar flexion is 70 degrees with low back pain. Extension is 20 degrees with low back pain. Trendelenburg test is negative. There is tenderness over the lumbosacral area and the mid thoracic area but no upper thoracic tenderness. No spasm is noted. Limb lengths are symmetric. Sacroiliac joints are completely nontender. Abductor mechanisms are nontender. Deep tendon reflexes are +2 at the knees symmetric, +2 at the Achilles symmetric and +2 at the posterior tibialis tendon symmetric.

Calf circumferential is 32.5 cm left and 33.0 cm right. Thigh circumference a handbreadth above the patella is 41 cm left and 41.5 cm.

No sciatic tension is noted right or left. Hips have full range of motion with no irritability. Knees have full range of motion with normal stability of the cruciate and collateral ligaments. Ankle and subtalar joints are supple symmetrically.

The claimant does have what appears to be a very low grade maculopapular rash involving her lower legs symmetrically and even her lower arms symmetrically. It is not pruritic. Motor examination of the hips is 5/5 in flexion, extension, abduction, adduction and symmetric. Motor examination of the knees is 5/5 in flexion and extension symmetrically. Motor examination of the ankles is 5/5 in dorsiflexion, plantar flexion, eversion and inversion symmetrically. Knee alignment is slight valgus left and neutral alignment right. DISCUSSION

In response to the specific cover letter questions: Causation Questions:

1) Please state each diagnosis found.

The claimant's accepted condition is lumbar strain. Additional potential diagnosis unrelated to her industrial injury would be probable inflammatory spondyloarthropathy unrelated to the industrial injury and not affected by the industrial injury. The claimant's symptoms of early morning stiffness and the relative recalcitrance of her to respond to physical therapy further gives support to this potential diagnosis, however, as noted above, this is not caused or affected by the industrial injury.

2) Please state whether each diagnosis is related to the industrial injury, and consistent with the mechanism of injury, on a more probable than not basis. See above.

Impairment Rating:

Claim Number: SM18944

Re: Karie Kelly

July 31, 2025 Page 5

3) If the worker’s condition is medically fixed and stable? If so, is there any impairment due solely to the industrial injury? If so, please provide us with an impairment rating in accordance with the RCW and WAC guidelines. Please also specify all objective findings upon which any rating is based.

The claimant is at maximum medical improvement at this point. Her industrial injury condition itself is lumbar strain. At this time, there are no residual objective findings and under Washington Administrative Code 296-20-280, she is a category 1. James Hazel, M.D.

Orthopedic Surgery, Board Certified

License Number: MD00026478

Please call if questions: 509-***-****

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