Our client, Sam, went to the Headache and Pain Management Center for his regular appointment. Here is what was recorded in the office notes:
“Sam presents today for a follow-up visit. The pain is showing improvement with treatment. The patient rates their pain today as a 3.5/10 on the pain scale as compared to a 3.5/10 at the last visit. The location of their pain is described as right shoulder and left shoulder. The patient describes their pain as throbbing, aching and burning. There are no medication changes made at this visit. He is doing well with the combination of Vicoprofen, Voltaren gel and Lidoderm patches. He is able to manage his pain and is unchanged from his previous visits. He had undergone 3 surgical interventions on the shoulder, but the area has continued to deteriorate.
Analgesia: The patient’s degree of pain relief is not changed from previous visit and being managed with medication.
Activities of Daily Living: The patient does show improvement in ability to perform on a daily basis.
Sam stated that his moods have been OK and stable. He has been looking forward to fishing, and he and friends are going on a fishing trip. Sam has been taking Citalopram 40 mg. daily for about one year. He stated that the medication has helped him control his depression and has even helped him with sleep problems. He stated that he keeps busy everyday by watching his two-year-old grandson while his parents work.”
What is wrong with what Sam talked about with his doctor?
Sam is obviously in a lot of pain or he would not be going to the Headache and Pain Management Center in the first place. Sam would not be taking all of these medications if he was healthy enough to go to work. He wouldn’t be taking medication for depression if the major changes in his life — caused by his work injury — were not overwhelming him.
Unfortunately, we can tell you from experience that when Sam appears in front of the Social Security Judge or the Workers’ Compensation Judge, the severity of his difficulties may quickly be overshadowed by the innocent discussion about a fishing trip or being a stay-at-home grandpop.
You must remember that what you say can always be misinterpreted. Some judges recognize that going fishing is therapy and being able to help your children by babysitting your grandchildren reinforces your self-worth. However, the lawyers and insurance companies opposing your claim will be looking for a way to call into question the believability of your complaints of severe pain and restricted lifestyle. They will distort these positive moments in your life and use them against you.
So next time you visit the doctor, remember Sam!