Urgent Care
CA WC Med Legal
Physical Exam Charades
Industrial or non Industrial
Occupational Exposures
100
A 32F farm worker is sent into your clinic after exposure to unknown substance while working without any form of PPE. She now has increased drooling, diaphoresis, rhinorrhea, and increased work of breathing. After taking appropriate actions you proceed to the physical exam and find wheezing diffusely, miosis of the eyes.
What is the diagnosis and management?
Organophosphate poisoning
Atropine, pralidoxime, and may need benzo PRN if status epi
100
33F RHD US Tech has a Right sided rotator cuff tear DOI: 1/1/2022, she has undergone all indicated treatment and Ortho has signed off the case. Surgery was performed 2/1/2022.
We are now at 4/1/2022 and are making the W MMI. She has no issues with ROM, sensation, or pain. Her only limitation is a feeling of decreased strength. On exam she has 40% of expected strength findings when compared to her non dominant left.
Can you make her MMI with rated disability based off of strength per the AMA 5th guide on 4/1/2022? If not, why?
No.
Page 508 under 16.8 paragraph 3:
"Maximum strength is usually not regained for at least a year after an injury or surgical procedure.
Because impairment is evaluated when the individual has reached MMI, strength can only be applied as a measure when a year or more has passed since time of injury of surgery. "
100
A 40F RHD Admin Assistant presents to LLU OMC with intermittent numbness and tingling over her thumb, index finger, and half of her middle finger on the ventral side, symptoms are only on her right hand. On exam Tinel and Phalen are negative.
Name a few things you could ask during interview or perform during the exam to help support CTS vs. Pronator Syndrome?
Pronator syndrome: concerns of heaviness, TTP over pronator teres (4 cm distal to cubital crease), no night pain or weakness
CTS: phalen, tinel flick sign +, nighttime numbness burning tingling of hand.
100
Which of the following is a PRESUMPTIVE work relates illness?
A. A factory worker with De Quervains Tenosynovitis
B. A police officer with a runny nose
C. A firefighter with cancer of the lung
D. A bedside nurse with low back pain
C. A firefighter with cancer of the lung
In California's Workers' Compensation system, there are specific laws covering injuries that are legally presumed to be caused by certain types of employment. A presumption is a legal concept that shifts the burden of proof in an injury claim from the employee to the employer.
100
Trimellitic anhydride (TMA) exposure has been associated with all of the following EXCEPT:
A) Rhinitis
B) Hemorrhagic pneumonitis
C) Lung cancer
D) Hemolytic anemia
The correct answer is: C
TMA acts as a hapten, forming antigenic protein complexes with human proteins. Exposed individuals have developed rhinitis, asthma, hemorrhagic pneumonitis, and hemolytic anemia secondary to host immune response to these haptens. TMA has not been associated with lung cancer.
200
A 22M EVS worker was cleaning bathrooms with industrial cleaners. During that time the fluids splashed and hit his right eye without any PPE. He feels immediate burning of the eye
What is the immediate next step?
Irrigate the eye! Even if the water is tap!
Once the patient arrives at the hospital, ocular irrigation must resume until the pH of the ocular surface is between 7.0 and 7.2. This may require 2 liters of irrigation for mild injuries and up to 10 liters for more severe injuries. Irrigation should continue for a minimum of 30 minutes. Severe injuries may take 2 to 4 hours of continuous irrigation for adequate decontamination
200
What are the requirements for a psychiatric injury to be compensable? Such as:
- What % is required of the predominant cause
- Required employment duration with current employer?
- An injured worker must prove that the “actual events of employment” were the “predominant cause” (presumed to be more than 50%) among all the combined causes of the psychiatric injury.
- For psychiatric injuries that result from a violent act or from direct exposure to (i.e., observation of) a significant violent act, the actual events of employment must have been a “substantial cause” of the injury in that they contributed at least 35% of the causation from all sources combined
- 6 months
https://www.dir.ca.gov/dwc/medicalunit/toc.pdf
200
A 34M Teacher presents to clinic after inversion ankle injury. You suspect the PTF (posterior talofibular ligament) is injured. While performing the Talar tilt, what position would you place the foot/ankle to test the PTF?
Dorsiflexion PTF
Neutral CF
Plantar flexion ATF
200
The background: A Female Surgeon who is married but having an affair with a coworker.
The husband of the surgeon finds out about the affair and shows up to the hospital she works at with a gun.
During his rampage he shoots a security guard, the female surgeon, and the male with whom the female surgeon was having an affair with. They are all stabilized and the shooter is contained.
Which of the 3 cases are industrial?
1. Female Surgeon
2. The Security Guard
3. The male coworker with whom the the surgeon was having an affair with
Industrial: Security Guard and and Male coworker
Security guard - obvious performing JD AOE/COE
Male coworker - they decided that he would have only been found at his place of employment and therefore considered industrial (COE)
Female surgeon - they ruled that given this individual could have been assaulted anywhere (home, community, work). They also ruled that actions were not attributed anywhere to her JD, AOE, or COE.
200
Wool handlers are most likely to be exposed to which of the following biologic hazards:
A) Psittacosis
B) Candidiasis
C) Anthrax
D) Sporotrichosis
The correct answer is: C
Anthrax is a bacillary infection causing skin ulceration that affects handlers of hides, wool, and goat hair. Psittacosis is a chlamydial infection transmitted by infected birds and is commonly seen in bird fanciers. Brucellosis is found in veterinarians, slaughterhouse workers, and farmers. Sporotrichosis is typically found in horticulturalists, whereas candidiasis is seen in workers whose hands are frequently wet and prone to maceration, such as dishwashers.
300
55M has low back pain that radiates down his left buttock and the posterior thigh to his knee after he lifted heavy boxes at work about 15 hours ago. He has been having urinary incontinence since this event. His ankle reflex is absent on the left side, and he has decreased pinprick sensation in the perianal region. Straight-leg raises causes a increase in pain in the leg and posterior thigh.
What is the next step in management?
Cauda equina syndrome--> Send to ED with NSGY or Ortho Spine for URGENT/STAT decompression
300
32M warehouse worker presents with acute low back pain after lifting incident at the end of his shift. You tell him to go home and take OTC Ibuprofen (200 mg) four times tonight, 3x times tomorrow morning (after eating) Return to work without work restrictions the following day.
Is this first aid or industrial injury?
Industrial - gave prescription strength dosing of a nonprescription drug.
300
A 50F PMH DMII had a shoulder injury that was then treated with limited movement. She now presents to you with severe pain over the shoulder an MRI shows the following:
Show what you would find on exam if you asked the patient to perform external rotation of both of her arms.
Symmetric ROM loss of both AROM and PROM.
One arm should be stuck compared to the other.
300
W was employed as a bus driver for Greyhound. Her hours of employment were from 5 p.m. to 5 a.m. During her 41-minute layover/break (1:45 AM), she left the Greyhound bus station at Seventh Street, crossed Seventh and walked about half a block to Foster's Restaurant at the corner of Seventh and Market Streets.
She purchased a cup of coffee and sat down at a table where a man unknown to her attempted to converse. Upon her refusal to talk to him, the man attacked W causing her disability. Of note, there is a vending machine and small shop on the greyhound site.
Is this injury work related?
Yes proven in a court of law.
Greyhound's operating supervisor knew that drivers went to Foster's for coffee. The commission found that the W's disability arose out of and in the course of employment and made an award for temporary disability.
The petitioner contends that the applicant's errand was entirely for her own pleasure and was unrelated in any way to her employment.
300
Effects of acute radiation exposure on the central nervous system can be observed at doses of:
A) 1000 rads
B) 500 rads
C) 250 rads
D) 125 rads
The correct answer is: A
CNS syndrome, where an electrolytic imbalance from excessive ionization causes nervous system dysfunction, does not occur until about 1000 rads of total body irradiation.
400
A 40M XR tech presents to clinic after attempting to catch a falling patient with both arms supinated. He claims he heard a pop. You see the following on exam:
What is the diagnosis? What is best next management?
1. Distal biceps avulsion/tear/rupture
2. MRI, STAT referral to Ortho
400
56F RN presents to OMC for evaluation of lower back injury after a lifting incident. She had a prior WC 4 years prior for her lower back and was discharged. Of note her MRI showed disc bulging between L3-L4 mild in nature.
For her current case, after 1 year of treatment she has persistent radicular symptoms and loss of ROM of her back. Her repeat MRI shows severe unilateral disc bulging.
Is this an exacerbation or aggravation?
Aggravation
An exacerbation results when a pre-existing condition is made worse temporarily by a new injury but will eventually return to the same physical condition as before the injury.
On the other hand, an aggravation occurs when a pre-existing condition is made worse permanently by the new injury.
400
A 42M groundskeeper presents to LLU OMC for new injury of low back pain. The employer reaches out to you ahead of time and lets you know that the individual has not been performing well in their job duties and has not been happy in their role and that they believe the employee may be faking or exaggerating symptoms.
To document a + Waddell sign name at least 3 categories you should find on exam.
Waddell’s sign 8 clinical signs are divided into 5 broad categories that include[1]
- Superficial and non-anatomic tenderness
- Axial loading and acetabular rotation simulation
- Distraction
- Regional sensory disturbance and weakness
- Overreaction
- Superficial tenderness: Tenderness over a wide area of lumbar skin to light touch or pinch.
- Non-anatomic tenderness: Deep tenderness over a wide area that crosses over non-anatomic boundaries.
- Axial loading: In axial loading patient stands and the examiner presses downwards vertically on the patient’s head, eliciting lumbar pain.
- Acetabular rotation: The examiner rotates the shoulder and the pelvis passively in the same plane while the patient is standing. It is a positive sign if pain is elicited in the first 30 degrees of rotation.
- Distracted straight leg raise discrepancy: In distraction test, the same positive physical finding is tested but while the patient is distracted, which can be achieved by testing a body part of the patient and observing another. Straight Leg Raising test can be used as a distraction test by using its variations. The test is positive when the patient reports pain on formal SLR examination such as on supine and the pain markedly decrease on performing the distracted SLR when the examiner extends the knee with the patient sitting.
- Regional sensory disturbance: The patient’s reports pain that follows a stocking-like disturbance and doesn’t follow a dermatomal pattern.
- Regional weakness: Weakness or cogwheel “giving away” that can’t be explained on neuroanatomical basis.
- Overreaction: Which is exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later.
3/5 = + test
400
An instructor for a culinary school, who had just finished teaching a class, collided with a pedestrian while driving from the school back home.
Important facts:
1. the employer occasionally required that the W use his own vehicle to travel to events held outside of the school
2. the instructor was transporting his tools (chef knives) for work and uniform (chef jacket), which needed to be laundered and used for work.
Is the employer liable?
No- Coming and Going rule: "the employer is not liable for injuries which occur during an employee's regular/routine commute."
Jorge v. Culinary Institute of America (2016) 3 Cal.App.5th 382
Ultimately, the vehicle used by the instructor was not material to the employer’s business, especially in the context of the accident. Accordingly, it was decided that the instructor was not acting within the course and scope of employment; rather, the “Going and Coming” rule applied, resulting in non-liability for the employer in this instance.
400
Which of the following can cause a parkinsonian movement disorder?
A) Trichloroethylene
B) MPTP
C) Arsine
D) Acrylamide
The correct answer is: B
MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine), a meperidine derivative, causes a parkinsonian movement disorder.
https://www.cdc.gov/mmwr/preview/mmwrhtml/00000360.htm
500
A 47M construction worker is brought in by his supervisor after his coworkers said he had been "acting funny". The worker is GCS 10. As you move onto the physical exam you find the following bilaterally:
What has happened to this worker?
Physical exam finding: papilledema, increased ICP likely secondary to trauma Multiple different dx could be present needs head imaging STAT, send to ED may need NSGY.
500
A 34M RN at LLU who also works at Arrowhead as an RN (bedside nursing at LLU, clerical desk work at Arrowhead), presents for severe lower back injury after lifting incident at work. He is given a a work restriction of no lifting more than 5 lbs and no bending/twisting.
His LLU supervisor sends him home as they cannot accommodate.
His Arrowhead supervisor informs him that he is able to continue working.
W does not show up to LLU shifts as they cannot accommodate but is getting full time pay from Arrowhead.
Will the W be given compensation as part of his temporary disability through LLU WC?
Yes, kind of.
Needs to be after first 3 days but then yes.
Income from work outside the regular job does not affect TD payments.
Important reminder: Temporary disability is not paid to injured workers for the first three days of missed work unless they are hospitalized or miss more than 14 days of work.
https://www.dir.ca.gov/dwc/medicalunit/toc.pdf
500
A 35F RN who also loves to ride road bikes on her off time presents with sensory loss of her little finger and 1/2 of her ring finger. She also has some motor loss of her little finger. You want to confirm your suspicion that she has adductor pollicis weakness secondary to ulnar nerve paralysis.
What special test can you do to confirm your suspicion?
Froment sign
Patient holds a paper between thumb and index finger. Clinician tugs paper away.
500
23M working for Poso Canal Company as a mechanic.
On DOI, he and three fellow employees decided to swim in a nearby canal owned by another company. It was 105 degrees in the shade, 109 or 110 degrees inside the shed where they were working.
At 3 o'clock in the afternoon, W dove into the water from the canal bank, struck his head, and suffered injuries,
Poso employees were accustomed to take coffee breaks or work breaks, as respites from their labors. Such breaks were taken on or off Poso premises, and for varying lengths of time. On the day of the accident, he had had no prior afternoon break. The work shift was scheduled to end at 4:30 p.m., from which it may be inferred that the four swimming employees intended to return to work. The canal in which they swam was 200 feet from the shed in which they were working, and 20 feet from Poso property.
Is this work related?
Yes
Personal Comfort Doctrine applied
"STATE COMPENSATION INSURANCE FUND, Petitioner, v. WORKMEN'S COMPENSATION APPEALS BOARD and JOHN RAYMOND CARDOZA, Respondents."
These holdings are in accord with the "personal comfort" doctrine, under which the course of employment is not considered broken by certain acts relating to the personal comfort of the employee, as such acts are helpful to the employer in that they aid in efficient performance by the employee.
On the case: In the present case the evidence supports the inference that some swimming on company time in the nearby canal, although not encouraged, would be tolerated, and that on a day of extreme heat such as here involved the cooling effect of the swim during a permitted work break would improve efficiency of the employees. Under such circumstances, and in the light of the established principle of liberal construction in favor of the employee (Reinert v. Industrial Acc. Com. (1956) 46 Cal. 2d 349, 354 [294 P.2d 713]; California Cas. Indem. Exchange v. Industrial Acc. Com. (Cooper), supra, 21 Cal. 2d 751, 760), the award of benefits should not be disturbed.
The award is affirmed.
500
A 30 year-old battery maker presents with a neuropsychiatric disorder with ataxia and tremor. Which one of the following elements is the MOST LIKELY cause?
A) Mercury
B) Magnesium
C) Copper
D) Chromium
The correct answer is: A
Mercury toxicity must be considered in workers with otherwise unexplained peripheral neuropathy, tremor, ataxia, and psychiatric symptoms including confusion and depression.