PATIENT AM

 

IME Kirkpatrick WORD Doc with Highlights: Click Here

IME Rauck WORD Doc with Highlights: Click Here

IME Rauck PDF Doc: Click Here

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The Daubert Standard

The failure to address the diagnosis of CRPS on a scientific basis raises the specter of noncompliance with the Daubert standard for expert testimony. As you know, the Daubert factors include methods and procedures that may be tested, the known and potential rate of error in these processes, if they have been subjected to peer review by the expert's peers in his or her field, if there are standards that control the operation of techniques and the acceptance of the methods used.

  • See the 1994 diagnostic criteria for CRPS published by the International Association for the Study of Pain.
  • See the 2010 Budapest diagnostic criteria for CRPS published in the journal Pain.
  • See the publication by Dr. Kirkpatrick and colleagues on including speading CRPS symptoms in the diagnostic criteria for CRPS to be published in the 2020 July issue of the Clinical Journal of Pain

 

 

 

Dr. Kirkpatrick Dr. Rauck

1-Continuing pain, which is disproportionate to any inciting event

Yes - Chronic pain in the upper right region of body documented at the Miami Children's Hospital Emergency Room for the first time four days after the bike accident. (November 8, 2014)

NOTE: The hospital record of 11/8/2014 establishes that the bike accident is causally related to the development of CRPS in the upper right extremity with subsequent spreading throughout the body. There is no evidence of problems in the upper right region of the patient's body prior to the bike accident.

1-Continuing pain, which is disproportionate to any inciting event

Yes - Chronic pain in the upper right region of body documented at the Miami Children's Hospital Emergency Room for the first time four days after the bike accident. (November 8, 2014)

2-Must report at least one symptom in three of the four following categories:

  • Sensory: reports of hyperesthesia and/or allodynia

Yes- Allodynia (Page 2)
Yes- Hyperesthesia - "Increased sensitivity to light and sound". (Page 1)

NOTE: Hyperesthesia is defined as an increase in the sensitivity of any of your senses, such as sight, sound, touch, and smell. It can affect just one or all of the senses.

  • Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry

Yes- Asymmetrical warm sensations (Page 2)
Yes -Asymmetrical purple color changes (Page 2)

  • Sudomotor/edema: reports of edema and/or sweating changes and/or sweating

Yes- Asymmetrical swelling (Page 2)
Yes- Asymmetrical sweating - Prior to sympathectomy (Page 2)

  • Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

Yes- Decrease range of motion (Page 2)
Yes- Weakness (Page 2)
Yes- Dystonia(Page 2)
Yes- Asymmetrical brittle nails - right side (Page 2)

 

 

 

 

2-Must report at least one symptom in three of the four following categories:

  • Sensory: reports of hyperesthesia and/or allodynia

Yes- Hyperesthesia - "Increased sensitivity to sound, light and touch, including clothing". (Pages 8, 9 and 10)
Yes- "Allodynia to pinprick." (Page 2)

  • Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry.

Yes- Right hand turns blue. Page 8.

SEE NOTE BELOW

  • Sudomotor/edema: reports of edema and/or sweating changes and/or sweating

SEE NOTE BELOW

  • Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

Yes- "still experiencing weakness" in fingers. (Page 5)
Yes- Right hand stays in a "closed or clenched position" consistent with dystonia. (Pages 4 and 10)

NOTE:

Identifying abnormal function of the sympathetic nervous system is key to making the diagnosis of CRPS. In taking the clinical history of the patient, Dr. Rauck (Dr. R) failed to evaluate the patient for abnormal function of the sympathetic nervous system. Either through incompetence or with the intention to conceal the diagnosis of CRPS, Dr. R failed to objectively evaluate the patient for CRPS.

The patient had a sympathetically performed which would create abnormal function of the sympathetic nervous system. Dr. R failed to question the patient for abnormal function of the sympathetic nervous system before the sympathectomy had been performed

For example:

In the video, he never questioned the patient about asymmetrical changes in temperature in the affected regions of the patient's body before the sympathectomy.

In the video, he never question the patient about asymmetrical changes and sweating or swelling or sweating before the sympathectomy.

Even when he questioned the patient about asymmetrical changes in color in her upper extremities, he minimized in his report the significance of this characteristic finding with CRPS.

For example, in his report he wrote, "She states that there are only been an occasional time that her fingers in the right hand would turn blue." However, in the video, the patient stated, "The fingers turn blue mainly in the right hand."


3-Must display at least one sign at time of evaluation in two or more of the following categories:

  • Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)

YES- Asymmetrical allodynia (Page 3)

NOTE: Demonstrated objectively using quantitative sensory testing.

  • Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or asymmetry

NO

  • Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry

NO

  • Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

YES-Asymmetrical decrease range of motion (Page 2)
YES-Asymmetrical weakness (Page 2)
YES- Dystonia (Page 2)
YES-Asymmetrical atrophy (Page 2)

 

 


3-Must display at least one sign at time of evaluation in two or more of the following categories:

  • Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)

    YES- Asymmetrical allodynia (Page 10)
    YES- Tenderness in upper chest in a widespread distribution. (Page 10)

 

  • Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or asymmetry

SEE NOTES BELOW ABOUT THE IME VIDEO: CLICK HERE

  • Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry

SEE NOTES BELOW ABOUT THE IME VIDEO: CLICK HERE

  • Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

    YES- Deceased range of motion of right hand. Right hand went into a curled position when splint was removed which is consistent with dystonia. (Page 11) In the video, the patient obviously had severe bilateral dytonia of the upper extremities with the right side being worse than the left. Yet the word "dystonia" is not reported as a finding either as a symptom or sign of CRPS. Dystonia is a characteristic finding in patients with CRPS.

On March 16, 2016, Dr. Andrew Sherman, diagnosed "dystonia" in the patient.


 

4-There is no other diagnosis that better explains the signs and symptoms

YES- CRPS best explains the signs and symptoms

4-There is no other diagnosis that better explains the signs and symptoms

YES- CRPS best explains the signs and symptoms

 

 

GENERAL NOTES ABOUT THE VIDEO OF THE IME PERFORMED BY DR. RAUCK

Timecode 7 minutes:

Dr. R is not current on the scientific literature. Pain scores are considered invalid in quantifying the patient’s pain experience with chronic pain. Yet, Dr. R kept asking the patient to provide pain scores.

Timecode 47 minutes:

The patient tells Dr. R several times that compression on the skin helps with the pain, while light touch causes extreme pain. This observation is a characteristic finding of patients with CRPS and yet this finding is not reported in his dictation.

There was no evidence of antalgic gait (a limp) during examination. However, Dr. R failed to ask the patient to walk on her heels and toes as part of his physical exam. Having the patient walking on her heels and toes might have demonstrated significant physical impairment below her waist. Of course, demonstrating severe physical does not support Dr. R's argument that the case is primarily a psychogenic disorder. Also, Dr. R failed to document sensitivity to light touch during his physical examination below the waist.

Time code 49 minutes:

The patient did not remove her shoes during the physical examination.

Dr. R made little effort to examine the patient for physical impairment below her waist other than to ask her to walk.

 

 

 

 

The following two videos demonstrate that Dr. Kirkpatrick uses more objective methodology than Dr. Harden (2015 video) in making the diagnosis of CRPS:

Physical Examination by Dr. Kirkpatrick

Physical Examination by Dr. Harden