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Stafford v. Talbot

United States District Court, C.D. Illinois, Urbana Division

January 7, 2015

SHAWN L. STAFFORD, Plaintiff,
v.
DR. PAUL TALBOT, Defendant.

OPINION

HAROLD A. BAKER, District Judge.

This case is before the court for ruling on the Motion for Summary Judgment (#60) filed by Defendant Dr. Paul Talbot. This court has carefully considered Defendant's Motion (#60), Plaintiff's Response (#65), Defendant's Reply (#66), and all of the documents provided. Following this careful and thorough consideration, Defendant's Motion for Summary Judgment (#60) is GRANTED.

FACTS[1]

Plaintiff is an inmate incarcerated with the Illinois Department of Corrections at the Danville Correctional Center. Defendant is a physician licensed to practice medicine in the State of Illinois and has been the Medical Director at the Danville Correctional Center since October 26, 2009. Plaintiff testified at his deposition that he injured his back in a fall in 2000, before he was incarcerated. Defendant first saw Plaintiff on November 16, 2009, for complaints of chronic low back pain. Defendant's physical examination showed that Plaintiff walked with a normal gait and no antalgia, which means there was no evidence of pain, such as limping. Plaintiff's straight leg raise (SLR) test was normal. The SLR test is done by placing the patient on his back and passively lifting one leg either while the patient is seated or lying down. This SLR test is to check for radiculopathy, meaning a nerve that is under tension anywhere from the lumbar disc to the ankle. On November 16, 2009, Plaintiff had normal muscle tone and strength. Defendant stated in his affidavit that his assessment that day was non-specific pain that was inconsistent with the examination. Plaintiff had been taking 600 mg of Ibuprofen twice per day. Defendant made no new medication orders but advised Plaintiff that he could get Tylenol or Ibuprofen through the commissary. According to Plaintiff, the commissary did not offer Ibuprofen. Plaintiff stated that he was able to get prescriptions for Ibuprofen from a psychiatrist and a P.A.

Plaintiff saw a physician assistant (PA) in April 2010. The PA had reviewed X-rays done in 2001 and 2009, which he noted showed degenerative changes at the sacroiliac joints, which are the joints between the sacrum and the ilium of the pelvis. The PA wrote Plaintiff a prescription for Ibuprofen 600 mg twice per day for two months for pain and also gave Plaintiff medication for his skin condition, including T-gel shampoo. The Ibuprofen was renewed on July 19, 2010.

Defendant saw Plaintiff on December 3, 2010, for medication renewal. On that visit, Plaintiff got up from the stool and walked normally with no antalgia. Defendant performed a Patrick's or figure four test, which is a manipulation designed to elevate the hip and sacroiliac joint, and is done by flexing, abducting, and externally rotating the leg. This test elicited mild tenderness more on the left than the right with less than full extension on the left. Defendant's assessment was non-specific degenerative joint disease of the left hip. Defendant prescribed Ibuprofen 600 mg twice per day for two weeks.[2] Defendant also ordered an X-ray of the left hip. The X-ray report, dated December 9, 2010, showed no fracture or significant arthritic change.

Plaintiff testified at his deposition that he could have put in for sick call when his two week supply of Ibuprofen ran out, but he did not do that. Plaintiff testified that, instead, he tried to get Mary Miller, the Medical Department Administrator, to review the situation. Plaintiff testified that he filled out a grievance and the grievance counselor put him in to see P.A. Tindera. Plaintiff saw Tindera on March 28, 2011, for complaints of dermatitis capitis and low back pain with radiculopathy. Tindera provided T-gel shampoo, Naproxen (500 mg twice per day) and Neurontin (300 mg three times per day). Defendant stated in his affidavit that Neurontin (Gabapentin) is an anti-seizure medication that is sometimes prescribed to treat nerve pain. Plaintiff saw Tindera again on May 20, 2011, for complaints of dermatitis of the scalp and lumbar radiculopathy or radiating pain or weakness. Tindera provided T-gel shampoo for the dermatitis and Naproxen 500 mg twice per day for three months. Tindera also increased the Neurontin to 300 mg twice in the morning and three times in the evening and prescribed Tramadol 50 mg at bedtime. Tramadol is a narcotic-like pain reliever for severe pain.

Tindera also ordered a low-back X-ray. The X-ray report, dated May 26, 2011, stated:

FINDINGS: There is grade I anterolisthesis at L5/S1, likely due to chronic bilateral pars defect. The anterolisthesis appears more prominent on the flexion position, indicating dynamic instability. Mild degenerative changes are seen at this level with osteophyte formation. The vertebral body heights are maintained without fracture.

In his affidavit, Defendant explained that a defect to the pars interarticularis portion of the vertebrae[3] is similar to a stress fracture. It may be congenital or due to stress, injury, or overuse. A pars defect is not uncommon and is often asymptomatic; however, if the fracture gap widens, instability can cause the L5 vertebrae to shift anteriorly over the sacrum, which is known as spondylolisthesis.[4] Depending on the severity, this anterior displacement can compress nerves and cause pain. Grade I slippage is the lowest degree and should be asymptomatic. Plaintiff's X-ray report indicated a grade I spondylolisthesis, which is minimal anterior slippage. Plaintiff's X-ray report also noted secondary osteoarthritis, which is the wearing away of the smooth bony surfaces, causing grinding in the affected joint and resulting discomfort.

Plaintiff followed up with Tindera on June 20, 2011, regarding seborrheic dermatitis and low back pain. Tindera ordered additional films taken of the low back and increased Plaintiff's Neurontin to 900 mg twice per day for five months. The X-ray films confirmed the bilateral pars defect. The X-ray report, dated June 27, 2011, stated, "[b]reak in pars interarticularis is present bilaterally at L5-S1."

Defendant saw Plaintiff on August 31, 2011, on a request for renewal of pain medication. At this time, Defendant reviewed the X-ray reports finding SI joint osteoarthritis and grade I vertebral slippage. Defendant observed that Plaintiff walked with a normal gait and no antalgia. Defendant performed an SLR test, which was negative. Plaintiff was able to heel/toe walk. Defendant assessed SI joint osteoarthritis with no radicular pain. Defendant prescribed Naproxen, an anti-inflammatory medication, at 500 mg twice per day for 90 days. Plaintiff continued to receive Neurontin according to Tindera's June 20 prescription until that prescription ran out on November 18, 2011.

Defendant next saw Plaintiff on November 30, 2011, after he signed up on nurse sick call for medication renewal. On examination, Plaintiff again had a normal gait with no antalgia. The SLR test was negative on both sides. Defendant's assessment was (1) mild seborrhea and (2) a normal physical examination with regard to the back pain. Defendant prescribed Naproxen 500 mg twice per day for 30 days for back pain and selenium sulfide shampoo for the skin condition.

Defendant next saw Plaintiff on January 6, 2012, after he signed up for a medication renewal. According to Plaintiff, he requested Neurontin, along with Naproxen and medicated shampoo. Defendant stated in his affidavit that Plaintiff reported that Naproxen helped his back and that T-gel shampoo worked better than selenium sulfide. Defendant prescribed T-gel shampoo and Naproxen 500 mg twice per day for 30 days.

Defendant saw Plaintiff again on February 1, 2012, for another medication renewal. Defendant again reviewed the May 2011 X-ray report. Defendant's physical examination showed Plaintiff in no acute distress. Plaintiff walked with a normal gait and no antalgia and had no tenderness of the lower back to palpation. A neurological examination for low back pain would normally consist of checking the deep tendon reflexes, performing a motor examination, and performing a sensory examination. The purpose is to identify nerve root impairment or a disc problem. Defendant checked Plaintiff's deep tendon reflexes by striking his knee and his ankle. It showed normal and bilateral deep tendon reflexes of the knees (for the L3-L4) and ankles (L5-S1). Defendant stated in his affidavit that Plaintiff was non-compliant with the voluntary portions of the motor examination, consisting of the left great toe dorsi flexion to check the L5 nerve root and L5-S1 interspace and the left foot plantar flexion for the S1 nerve root and S1-S2 interspace. The straight leg raise was negative while seated on both the left and right. Defendant's assessment was lumbar osteoarthritis per X-ray but intact S1 root (S1-S2 interspace) and L5 root (L5-S1 interspace). Defendant found that Plaintiff's subjective description of sensory radiation in the left foot was consistent with left S1-S2 distribution but objectively he had intact left deep tendon S1 reflexes judged by the left ankle jerk, suggesting no impairment. Defendant noted that sensory testing was deferred due to Plaintiff's lack of compliance with the motor testing.[5] Defendant renewed the T-gel shampoo and prescribed Naproxen 500 mg twice per day for 90 days for the osteoarthritis.

Defendant saw Plaintiff again on May 9, 2012, for medication renewal. Plaintiff reported an onset of pain in 2000 when he fell off of a log while doing a log jam removal. Plaintiff testified that his original physician in 2000 did not suggest surgery, telling Plaintiff he would have a 65% chance of getting better and a 35% chance of actually being worse than he was before the surgery. Plaintiff reported that triggers for pain are the weather and that it was worse when it was cold and wet outside. According to Defendant, Plaintiff's triggers for pain are consistent with osteoarthritis/degenerative joint disease. Plaintiff reported that his pain was better with Naproxen and Neurontin. Plaintiff reported that the pain felt like an ice pick, while pointing to L4-L5 disc space on the left side that radiates down his buttocks and posterior thigh with electric shock in his thigh and calf and burning in his calf down to the bottom of his foot.

Defendant noted that, objectively, Plaintiff was in no acute distress. The SLR test was negative. The figure-four test for hip pathology was positive on the left but there was no palpable tenderness. Neurological testing of the deep tendon reflexes was normal. Strength testing that required full effort and participation from Plaintiff showed motor and sensory deficits on the left. However, there was no corresponding quadriceps, hamstring, or calf muscle atrophy, as the calves were equal in diameter. Defendant stated in his affidavit that, if there was significant and chronic nerve denervation, it would cause the patient to use the affected side less and favor the other side. One would then expect to see atrophy and muscle asymmetry. Plaintiff had no disuse atrophy on the left side.

Defendant's assessment was (1) a subjective report of left lower extremity pain with intact reflexes and no disuse atrophy; (2) SI joint osteoarthritis per X-ray; (3) Grade 1 anterolisthesis at L5-S1 per X-ray; (4) rule out vasculopathy (disease of blood vessels) at left lower extremity; and (5) seborrhea capitis. As a follow-up to his assessment to rule out vasculopathy, an ankle brachial index test (ABT) was done on May 30, 2012. The test measures the blood ...


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