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Patient Name DOB: 02/01/YYYY
Medical Chronology/Summary
Confidential and privileged information
Usage guideline/Instructions
*Verbatim summary: All the medical details have been included “word by word’ or “as it is” from the provided medical records to avoid alteration of the meaning and to maintain the validity of the medical records. The sentence available in the medical record will be taken as it is without any changes to the tense.
*Case synopsis/Flow of events : For ease of reference and to know the glimpse of the case, we have provided a brief summary including the significant case details.
*Injury report: Injury report outlining the significant medical events/injuries is provided which will give a general picture of the case.
*Comments: We have included comments for any noteworthy communications, contradictory information, discrepancies, misinterpretation, missing records, clarifications, etc for your notification and understanding. The comments will appear in red italics as follows: “*Comments”
*Indecipherable notes/date: Illegible and missing dates are presented as “00/00/0000” (mm/dd/yyyy format). Illegible handwritten notes are left as a blank space “_____” with a note as “Illegible Notes” in heading reference.
*Patient’s History: Pre-existing history of the patient have been included in the history section
*Snapshot inclusion: If the provider name is not decipherable, then the snapshot of the signature is included. Snapshots of significant examinations and pictorial representation have been included for reference.
*De-Duplication: Duplicate records and repetitive details have been excluded.
General Instructions:The medical summary focuses on “Motor Vehicle Collision on 07/30/YYYY”, the injuries and clinical condition of XXXX as a result of accident, treatments rendered for the complaints and the progress of the condition.
Initial and final therapy evaluation has been summarized in detail. Interim visits have been presented cumulatively to avoid repetition and for ease of reference.
Page 1 of 27
Patient Name DOB: 02/01/YYYY
Injury Report:
DESCRIPTION DETAILSPrior injury details No prior injury details availableDate of injury 07/30/YYYYDescription of injury
Restrained driver in car stopped at red light struck from behind by another vehicle, positive airbags.
*Comments: Accident scene investigation report is not available for review.
Injuries/Diagnoses Headache Cervicalgia Contusion of bilateral shoulder, initial encounter Unspecified sprain of bilateral shoulder, initial encounter Myalgia Sprain of ligaments of cervical spine, initial encounter Sprain of ligaments of lumbar spine, initial encounter Sprain of joints and ligaments of other parts of neck, initial
encounter Spondylosis without myelopathy or radiculopathy, lumbosacral
region Low back pain Contusion of unspecified front wall of thorax, initial encounter Sprain of unspecified site of bilateral knee, initial encounter Trochanteric bursitis right hip Post traumatic cervical sprain/strain Lumbar sprain/strain Bilateral shoulder pain Cervicalgia/neck pain Bilateral knee pain
Treatments rendered
Pain medication Physical therapy Chiropractic therapy Acupuncture
Condition of the patient as per the last available record
As on 02/14/YYYY, patient complains of pain on neck, bilateral shoulder, back and bilateral knees. He tolerated PT well.
Page 2 of 27
Patient Name DOB: 02/01/YYYY
Patient History
Past Medical History: None as of available records
Surgical History: None as of available records
Family History: None as of available records
Social History: Denies alcohol use, smoke and recreational drugs
Allergy: No known allergies
Detailed Summary
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Summary of Post Injury Medical RecordsDate of Injury: 07/30/YYYY
07/30/YYYY Hospital/Provider Name
EMS/Ambulance Report:
Call information:Call received: 03:00:14Dispatched: 03:00:29En route: 03:02:37On scene: 03:05:20Patient contact: 03:07:00Left scene: 03:40:24At destination: 03:53:15Time on destination: 35 minutesTime to destination: 52 minutes
Disposition: Treated/transported
Unit#: 31H1 – 31H tour 2300-0700Ambulance – Land – BLSRun type to scene: Emergency (Immediate)Incident location: 999 Manhattan Bridge – Brooklyn, NY (Kings County)Incident location type: Scene of accident or acute event - Street/HighwayReceiving facility: 54- NYP Methodist Hospital (Hospital) – 506 6 street – Brooklyn, NY 11215Facility address: 506 6 street – Brooklyn, NY 11215Destination reason: Nearest facilityLoaded mileage: 4.8 (Total mileage 4.8)Crew members: Arnolda Butcher #2229, EMT Basic (DOC), Charles McCloskey, EMT Basic (DS) (DH)Moved to ambulance by: ChairTransport position: Sitting
Clinical:Onset date/time: 07/30/YYYY
18-20
Page 3 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Dispatch reason (EMD): MVA injury – Auto accident with injuriesChief complaint: My chest, shoulder and legs hurtsProvider impression: Chest painMechanism of injury: MVA to MV
Flowchart:Glasgow Coma Scale (GCS): 15Neurological: AlertInjury: Chest. Location modifier: External. Injury: Swelling. Injury modifier: MinorInjury: Back. Location modifier: Lumbar, right and left. Injury: Pain.Injury: Lower leg. Location modifier: Left. Injury: Pain.ABC:Airway: Partially obstructed – Difficulty swallowingBreathing: Normal Lung sounds: Clear, bilateralSkin condition: Normal
Head to toe:Head and neck: Left eye and right eye reactiveTreatment 1: BLS assessment
Vital signs:Blood Pressure (BP): 150/110Pulse: 82Respiration: 16Treatment: Med/Oxygen administration
Vehicle accident/safety equipment:Rear: Passenger rearExterior damage: MinorInterior damage: NoneSafety equipment: Lap belt, shoulder beltPatient position: 2Vehicle type: CarPosted speed limit: 40
Narrative history text: Upon EMS arrival 36 years old male found sitting in the driver side of his taxis. Patient is alert and oriented x3 with patient airway. Patient is complains of chest, left leg and right and left shoulder pain. Patient states the car hit me from the back and my chest hit the steering wheel.
Physical examination reveal positive ABC’s, positive Pupils Equal, Round, React to Light, Accommodation (PERRLA), positive chest pain with minor swelling, positive bilateral shoulder pain, positive left leg pain, positive lower back pain. Denies Loss of Consciousness (LOC), dizziness, Shortness of Breath (SOB), nausea, vomiting. Lung sounds clear – bilateral. Abdomen soft non-distended. Positive pulse monitor motor sensory x 4 extremities. Patient transferred safely to hospital 54 WOI.
Page 4 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
07/30/YYYY Hospital/Provider Name
Triage record:
Chief complaint: 07/30/YYYY @ 0449 amLynx mode of arrival: BLS/ambulanceChief complaint: Patient Brought In By Ambulance (BIBA) with complaints of chest pain and lower back pain status post MVA. Patient denies laceration or head injury. Patient ambulating on seenHospitalized/admitted within the past 30 days?: NoLevel of consciousness: Wide awakeSuspicion of abuse: Not applicableRecent travel within 21 days: N/AAllergy: YesVital signs/pain assessment: DoneESI: YesPatient EKG: YesPatient EKG order: EKG UrgentWeight unit of measure selection: LBSWeight LBS: 175 LBHeight: 67 inchDo you feel safe in your home: YesPatient expresses suicidal ideations?: No
Diagnoses: Chest pain Lower back MVA
Tracking acuity: 4- Less UrgentTracking group: NYMH ED tracking groupRecommended ESI Level: 4
Primary pain location: Lower backLaterality: BilateralPain score: 5/10
6-13
07/30/YYYY Hospital/Provider Name
ED record:
Chief complaint: Patient BIBA with complains of chest pain and lower back pain status post MVA. Patient denies LOC or head injury. Patient ambulating on seen.
History of present illness: The patient presents following motor vehicle collision. The onset was just prior to arrival. The Collision was rear impact. The patient was the driver. There were safety mechanisms including seat belt and airbag. The degree of pain is moderate. Therapy today: Emergency medical services. Associated symptoms: Chest pain and denies shortness of breath. No Past Medical History (PMH) with MVC just Prior To Arrival (PTA). Restrained driver in car stopped at red light struck from behind by another vehicle, positive airbags, unclear extent of damage to vehicle, assisted out by EMS, ambulatory on scene, now with multiple myalgias, anterior chest wall pain, Left Low Back Pain (L LBP), no focal weakness/numbness. No dizziness, no nausea vomiting.
13-17, 22-27, 29-38, 40-44
Page 5 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Review of systems:Constitutional symptoms: No fever no chills, no sweats.Skin symptoms: No rashEye symptoms: No recent vision problemsENMT symptoms: No ear painRespiratory symptoms: No shortness of breath no coughCardiovascular symptoms: No palpitationsGastrointestinal symptoms: No abdominal pain no nausea, no vomiting, no diarrhea, no constipation.Genitourinary symptoms: No dysuriaMusculoskeletal symptoms: Muscle pain, no joint pain.Neurologic symptoms: No dizzinessAdditional review of systems information: All other systems reviewed and otherwise negative.
Physical examination:BP: 123/67Pulse rate: 88 Beats Per Minute (BPM)Temperature: 98.0 degreeFRespiratory rate: 18 breaths/minuteOxygen saturation: 98%Primary pain location: Generalized, bilateral lower backLaterality: BilateralQuality: AchingDuration: >1 Day0 - 10 Pain Score: 5-6
Physical examination:General: Alert. No acute distress.Skin: Warm, dry, pink, intact.Head: Normocephalic. Atraumatic. Neck: Supple. Trachea midline. No tenderness.Eye: Pupils are equal, round and reactive to light.Ears, nose, mouth and throat: Oral mucosa moistCardiovascular: Regular rate and rhythm. No murmur. Respiratory: Lungs are clear to auscultation. Respirations are non-labored. Breath sounds are equal.Chest wall: No tenderness. No deformity. No seatbelt sign.Back: Non tender. Normal range of motion. Normal alignment. No step-offs. Musculoskeletal: mild left lumbar paraspinal tenderness. Bilateral trapezius tenderness. Ambulatory with antalgic gait.Gastrointestinal: Soft. Non tender. Non-distended. Normal bowel sounds. Neurological: Alert and oriented to person, place, time, and situation. No focal neurological deficit observed. No gross motor or sensory abnormalities.Psychiatric: Cooperative
Medical decision making: Rationale MSK pain status post MVC, patient ambulatory, no focal neuro symptoms. Motrin, chest X-ray, reassess. EKG
Page 6 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
unremarkable.
Re-examination/Re-evaluation: X-ray unremarkable, well appearing, discharge, instructions for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS).
Assessment: Motor vehicle accident
Plan of care:Condition: Improved, stable.Patient was given the following educational materials: Motor vehicle collisionFollow up with: Follow up with primary care provider Within 3 - 5 days.Counseled: Patient, regarding diagnosis, regarding diagnostic results, regarding treatment plan, patient indicated understanding of instructions.
ED discharge patient: Discharge, home
Discharge instructions: Given07/30/YYYY Hospital/Provider
NameChest X-ray Posterior Anterior (PA), lateral:
Reason for exam: MVA
Findings: Frontal and lateral chest radiographs. The cardiac silhouette and mediastinum are within normal limits. No
focal infiltrate, significant pleural effusion, vascular congestion or pneumothorax. Bony thorax is grossly intact.
Impression: No acute cardiopulmonary disease findings.
28
07/31/YYYY Hospital/Provider Name
Acupuncture therapy initial visit: (Illegible notes)
Subject: Complaint of neck pain, lower back pain, shoulder pain ___ ___ ribs pain
Objective: Moderate
Assessment/plan:Treatment site: Neck, right shoulder, _____Pain relief: Minimal Acupuncture points selected:
Procedure: 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
146
07/31/YYYY Hospital/Provider Name
Office visit for initial comprehensive examination:
Date of loss: 07/30/YYYY
147-151
Page 7 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
The patient is a 36 year old male with history on the above mentioned date for a motor vehicle accident. The patient was a driver of the vehicle (yellow cab driver, one passenger is inside). The vehicle was hit from behind.Patient went to Methodist Hospital.Did patient have prior accident: No.
As a result of the accident, the patient sustained injuries to the: Head – Frontal, temple, constant Neck Right shoulder Lower back Left knee Left leg Chest Ribs pain on both sides Short breath
Review of systems:This patient is presently taking medication: No. He have other medical condition.
Physical examination:The patient is cooperative. Gait is steady. Does not need assistance to walk.Pulse: FullTongue: White, yellow, thin, fur, redCervical spine: Tender. Restricted to the left/right lateral bending.Restricted Range of Motion (ROM) on rotation. Pain scale: 7/10.Lumbar spine: There is pain on motion of the trunk, extension, flexion, rotation, lateral bending. Pain scale: 7-8/10.Upper extremities: Shoulders: Restricted ROM – Bilateral. Restriction forward elevation. Backward elevation, abduction, adduction, internal external rotation.Lower extremities: Knees: Decreased ROM on the left. Tenderness noted over left. Pain scale: 8/10.Left leg: Pain noted, 8/10
Traditional Chinese Medicine (TCM) diagnosis:Chi/blood stagnation syndrome with involvement in meridian of Du Mai, LI, UB, SI, GB, ST, Ki
Comments: After taking a thorough history, performing an examination and listening to the patient’s complaints, it appears that casual relationship can be established between the patient’s initial symptoms and the accident of the above date.I would like to recommend that the patient begin acupuncture treatment as adjunctive therapy to other modalities to control pain and prevent further progression of disability. Patient has been advised to seek medical attention.
Diagnosis: Tension-type headache, unspecified, intractable Cervicalgia
Page 8 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Pain in right and left shoulder Sprain of ribs, initial encounter Low back pain Pain in left knee
Prognosis: Guarded at this time.08/01/YYYY-09/25/YYYY
Hospital/Provider Name
Interim Acupuncture therapy visits:
Treatment diagnosis: Tension-type headache, unspecified, intractable Cervicalgia Pain in right and left shoulder Sprain of ribs, initial encounter Low back pain Pain in left knee
He received Acupuncture therapy on following dates: 08/01/YYYY, 08/03/YYYY, 08/07/YYYY, 08/14/YYYY, 08/25/YYYY, 08/29/YYYY, 09/05/YYYY, 09/11/YYYY, 09/18/YYYY, 09/25/YYYY
*Comments: Only the initial and final visits have been elaborated. Interim visits have been presented cumulatively to avoid repetition and for ease of reference.
144-146
08/04/YYYY Hospital/Provider Name
Office visit for initial comprehensive examination:
Date of loss: 07/30/YYYY
The above patient presented himself today for an examination and treatment to this office due to present pain.Patient presented today for evaluation:MVA, in which this patient stated he was the driverPatient states restrainedImpact on the car: RearDescription work accident: Patient was hit by a high speed car from rear end.
The patient report he experienced these symptoms after the accident: Headache, neck pain, upper back pain, low back pain, right knee pain, bilateral shoulder pain, bilateral chest.
Patient reporting pain didn’t improve/increased. As result patient presented today seeking medical help.Currently as result of accident patient complaining of:Disturbed sleepHeadache, 9/10, constant, frontal/temporal/occipital/bilateral, throbbing/achingNeck pain, 10/10, constant, sharp/stabbing/achy/throbbing with radiation/ both shoulder and both scapular region upto elbow cramps of fingers bilateral with numbness/tingling.Back pain 9/10, constant, sharp/stabbing/burning/achy/throbbing with radiation to left lower extremity upto ankle and sometimes right side with numbness/tingling left occasionally.
72-80
Page 9 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Bilateral shoulder pain, 9/10 constant/achy/radiation to both upper extremities with numbness/tingling in the upper extremities.Hip pain ____/10Bilateral knee pain, 9/10, constant/achy/throbbing with radiation to left lower extremity with numbness sometime/tingling in lower extremity.
Pain is exacerbated by: Going up/down stairs, bending down, squatting, pushing, pulling, lifting, carrying heavy objects, prolonged standing, lying down, prolong sitting, standing up from a sitting position, prolonged walking
Physical examination:General appearance: Well developed, well nourished, in no acute distressBack: NormalExtremities: No edema. Pulses 2+ throughout
Cervical ROM Normal ROM Patient ROMFlexion 60 45 with painExtension 30 15 with painLeft rotation 45 25 with painRight rotation 45 25 with painLeft lateral flexion 30 15 with painRight lateral flexion 30 15 with pain
Cervical muscles appear symmetrical/moderate/tenderness/muscle spasm to upper, bilateral trapezius, bilateral rhomboid and bilateral paraspinal muscles C3, C4, C5, C6, C7 and C8.
Lumbosacral ROM Normal ROM Patient ROMFlexion 60 40 with painExtension 30 20 with painRight rotation 45 30 with painLeft rotation 45 30 with painRight lateral flexion 30 20 with painLeft lateral flexion 30 20 with pain
Bilateral upper and lower lumbar pain, paraspinal muscle, gluteus medius, piriformis muscle, mild sacroiliac pain and facets.
Thoracic spine: Tenderness and muscle spasm at T3-T12 paraspinal muscle, bilateral. Tenderness noted on anterior chest wall bilateral.
Bilateral shoulders Normal ROM Right LeftFlexion 180 150 with pain 140 with painExtension 50 50 with pain 50 with painAdduction 50 50 with pain 50 with painAbduction 180 150 with pain 140 with painInternal rotation 70 70 with pain 70 with painExternal rotation 80 70 with pain 70 with pain
Page 10 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Shoulders: Asymmetrical/moderate/bilateral tenderness pain with Acromioclavicular (AC) joint/ Glenohumeral Joint (GH) joint/supraspinatus both tenderness Rhomboids bilateral, infraspinatus bilateral, trapezius bilateral, deltoid bilateral. On palpation, negative impingement sign, bothElbow, wrist, hand, thumb, hips: Within Normal Limits (WNL). Positive Faber test, positive greater/trochanter/tenderness – bilaterally.
Bilateral Normal ROM Right LeftFlexion 180 130 130Extension 0 0 0Joint line pain Positive Positive
Ankle/foot: WNL
Neurological examination: Judgment are intact, CNII-XII grossly intact. Slow gait. Limited and mild pain with toe/heal walking. Normal coordination. Negative Romberg’s test.Motor exam: Normal bilateral extremities.Deep Tendon Reflexes (DTR): +2 all 4 extremitiesSensation: Intact upper and lower extremitiesStraight Leg Raising (SLR) test supine: Positive on right side 50°, positive on left, 45°.
Diagnosis: Headache Cervicalgia Contusion of bilateral shoulder, initial encounter Unspecified sprain of bilateral shoulder, initial encounter Myalgia Sprain of ligaments of cervical spine, initial encounter Sprain of ligaments of lumbar spine, initial encounter Sprain of joints and ligaments of other parts of neck, initial encounter Spondylosis without myelopathy or radiculopathy, lumbosacral region Low back pain Contusion of unspecified front wall of thorax, initial encounter Sprain of unspecified site of bilateral knee, initial encounter Trochanteric bursitis right hip
Treatment and plan: Physical therapy program 3-4 times per week for 4 weeks until the next
re-evaluation Computerized ROM and Manual Muscle Testing (MMT) treatment Outcome assessment narrative summary Physical capacity test Acupuncture Chiropractic
Page 11 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
*Comment: Chiropractic therapy was recommended as per this record. However, the corresponding records are not available.
Mobic 15 mg every day #30, Zanaflex 4 mg every night #30.
Patient is referred for the following: MRI bilateral shoulderFollow-up evaluation in: 2-3 weeks, patient is totally disabled 100%Has the patient missed work because of the injury/illness? YesIs the patient currently working? No
08/04/YYYY Hospital/Provider Name
Physical Therapy (PT) referral:
Treatment modalities: Hot moist Pack (HMP) and electric stimulation for thoracic, cervical and lumbar spine, bilateral shoulder and bilateral knee.
Procedures: Passive ROM, active ROM, neck/low back exercise, therapeutic massage and joint mobilization.
Treatment plan: Frequency – 3 to 4 times per week.
81, 143
08/07/YYYY Hospital/Provider Name
Physical therapy initial evaluation: (Illegible notes)
Present history: Positive MVA, driver, positive rear ended, EMS
Neck: 9/10. Middle back: 9/10. Lower back: 9/10Other: Bilateral shoulder ___ 6/10, bilateral knee ____ 9/10
Physical examination:Muscle spasm: Paracervical, paralumbarTenderness: Paracervical/paralumbar/bilateral shoulder/bilateral knee
ROM:Lumbar, bilateral shoulder, bilateral knee, ____: Restricted ____ pain.
Muscle assessment:All muscles of both Upper Extremity (UE)/Lower Extremity and trunk are grossly graded 5/5 or WNL.Paracervical 3/5Bilateral knee 3/5Bilateral shoulder 3-/5Paralumbar 3/5
Postural assessment: Increased lumbar lordosisGait analysis: Positive antalgic gaitFunctional assessment: Increased difficulty in prolonged sitting/standing.
Preliminary diagnosis: Headache Post traumatic cervical sprain/strain Lumbar sprain/strain Bilateral shoulder pain
141-142
Page 12 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Cervicalgia/neck pain Bilateral knee pain Lumbalgia/low back pain
Treatment plan: HP/CP, Electrical Stimulation (ES)/Transcutaneous electrical nerve stimulation (TENS), massage, therapeutic exercise
08/09/YYYY-01/25/YYYY
Hospital/Provider Name
Physical therapy interim visits:
Treatment diagnosis: Headache Post traumatic cervical sprain/strain Lumbar sprain/strain Bilateral shoulder pain Cervicalgia/neck pain Bilateral knee pain Lumbalgia/low back pain
PT modalities: Moist pack, electrical stimulation, active exercises, therapeutic massage
He received physical therapy on following dates: 08/09/YYYY, 08/10/YYYY, 08/14/YYYY, 08/16/YYYY, 08/17/YYYY, 08/21/YYYY, 08/22/YYYY, 08/24/YYYY, 08/29/YYYY, 08/30/YYYY, 09/05/YYYY, 09/06/YYYY, 09/07/YYYY, 09/11/YYYY, 09/13/YYYY, 09/18/YYYY, 09/20/YYYY, 09/25/YYYY, 09/26/YYYY, 10/03/YYYY, 10/05/YYYY, 10/10/YYYY, 10/11/YYYY, 10/17/YYYY, 10/23/YYYY, 10/25/YYYY, 10/30/YYYY, 11/02/YYYY, 11/22/YYYY, 11/27/YYYY, 11/29/YYYY, 12/06/YYYY, 12/12/YYYY, 12/18/YYYY, 01/05/YYYY, 01/08/YYYY, 01/17/YYYY, 01/18/YYYY, 01/25/YYYY
08/09/YYYY, 08/10/YYYY, 08/14/YYYY, 08/21/YYYY, 08/29/YYYY, 09/06/YYYY, 09/13/YYYY, 09/25/YYYY, 10/05/YYYY, 10/17/YYYY, 10/30/YYYY, 11/27/YYYY, 12/12/YYYY, 01/08/YYYY, 01/25/YYYY
*Comments: As per the treatment record, the patient had 41 visits of therapy sessions. However, there are only 17 physical therapy visit notes in the available medical records. Kindly verify
126-140, 142
08/09/YYYY Hospital/Provider Name
Outcome assessment testing summary report:
Date of accident: 07/30/YYYY
Headache disability index:Patient result: The outcomes assessment summary lists the current Headache Disability Index (NDI) "emotional " score compared to 52, "functional'' score compared to 48 , and " total" score compared to the worst possible headache score of 100.
Subjective knee score questionnaire:Patient results: The outcomes assessment summary list the current subjective knee score questionnaire score compared to the best possible knee health score of
88-106
Page 13 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
100.
Neck Disability Index (NDI):Patient result: The outcomes assessment summary list the current NDI score compared to the worst cervical spine health score of 100.
Oswestry low back pain disability questionnaire (revised):Patient result: The outcomes assessment summary list the current Oswestry low back pain disability questionnaire score compared to the worst low back health score of 100.
Roland Morris Disability Questionnaire:Patient result: The outcomes assessment summary list the current Roland Morris disability questionnaire score compared to the worst possible low back disability score of 24.
Shoulder Pain and Disability Index (SPADI):Patient result: The outcomes assessment summary list the current SPADI score compared to the worst possible score of 130.
08/24/YYYY Hospital/Provider Name
Office visit:
Spinal ROM exam:Impairment summaries:
The spine Cervical Thoracic Lumbar19% 0% 26%
WP region totals (combined) 19% 0% 26%WP spine total (combined) 40%
Left upper extremity ROM:Total UE impairment (combined): 16%WP impairment contr. by upper extremity: 10%
Left lower extremity ROM:Total LE impairment (combined): 32%WP impairment contr. by upper extremity: 13%
Right upper extremity ROM:Total UE impairment (combined): 17%WP impairment contr. by upper extremity: 10%
Right lower extremity ROM:Total LE impairment (combined): 32%WP impairment contr. by upper extremity: 13%
Final whole person impairment: 63%
MMT Left Right
176-186
Page 14 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Max CV Valid Max CV Valid Deficit
Neck flexion 10 lb 0% YesNeck extension 6 lb 0% YesKnee extension 13 lb 0% Yes 13 lb 0% Yes -2%
LeftShoulder flexion 8 lb 0% Yes 8 lb 0% Yes -1%
RightShoulder abduction 8 lb 0% Yes 8 lb 0% YesShoulder extension 9 lb 0% Yes 9 lb 0% Yes -1%
Right
Spine ROM Max Dev ValidCervical flexion 14° 1° YesCervical extension 16° 2° YesCervical left rotation 25° 3° YesCervical right rotation 24° 3° YesLumbar left lateral 8° 2° YesLumbar right lateral 10° 2°Lumbar minimum lordosis 28°Lumbar flexion 9° 1° YesLumbar extension 5° 2° YesSacral hip flexion 0° 0°Sacral hip extension 0° 0°
Extremity active ROM Left RightShoulder internal rotation 18° 16°Shoulder external rotation 14° 11°Shoulder flexion 119° 114°Shoulder extension 12° 10°Shoulder adduction 14° 16°Shoulder abduction 117° 120°Knee flexion 68° 65°Knee extension 57° 50°
.09/05/YYYY Hospital/Provider
NameFollow up visit:
Date of accident: 07/30/YYYY
Current treatment and procedures: Physical therapy Acupuncture chiropractic
Current complaints:Disturbed sleepHeadache. dizziness
54-62
Page 15 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Neck pain - intermittentLow back pain 8-9/10, radiating to left thigh, left legBilateral shoulder painBilateral knee pain
Other:Since the accident the patient is: Not workingPatient comes to the office: Car service
Physical examination:Patient appears to be in some pain and discomfort ____ROM of cervical, lumbar spine: SameMotor: Motor muscle tests normalDTRs: All normal
Neck and cervical ROM Normal ROM Patient ROMFlexion 0-60 40 with painExtension 0-50 20 with painRight rotation 0-80 30 with painLeft rotation 0-80 30 with painRight lateral flexion 0-45 20 with painLeft lateral flexion 0-45 20 with pain
There is tenderness to palpation with muscle spasm at right and left C3, 4, 5, 6, 7 paraspinals, bilateral trapezius, bilateral rhomboid.
Bilateral shoulders Normal ROM Right LeftForward flexion 0-180 100 150Backward extension 0-50 100 150Adduction 0-45 100 150Abduction 0-180 100 150Internal rotation 0-80 100 150External rotation 0-70 100 150
There was pain/tenderness at right/leftThere is tenderness of bilateral trapezius and bilateral both supraspinatus, infraspinatus bilateral, bilateral bicipital tendon.Impingement test negativeExamination of thoracic spine: Tenderness noted on bilateral rib cageElbow, wrist, hand, thumb: WNL
Examination of lumbar spine:There was tenderness at the lumbar paraspinal muscles at L L S1 right/leftLumbar paraspinals are mildly/moderately spastic on the right/left/both sideSpasms of lumbar paravertebral muscles form L1, L2, L3, L4, L5, S1 disc space right/leftActive trigger points noted on left facet right/left Sacroiliac Joint (SIJ), right/left gluteus medius.
Page 16 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Reactive spasms of right and left piriformis musclesSLR negative bilaterally.
Lumbar spine Normal ROM ExamFlexion 0-60 40 with painExtension 0-30 20 with painRight rotation 0-45 30 with painLeft rotation 0-45 30 with painRight lateral flexion 0-30 20 with painLeft lateral flexion 0-30 20 with pain
Physical examination of the bilateral hips:There was tenderness noted at right and leftPoint tenderness on palpation at the right and leftSpasms are present on palpation of the Psoas muscle in the right and leftROM of bilateral hips: Normal
Physical examination of bilateral knee:There was pain on motion on active and passive mobilization in right and left.McMurray test was negativeThere is tenderness to palpation on lateral aspect of the midline joint on the right and left knee.
ROM Normal Right LeftForward 0-135 130 with pain 130 with painExtension 0-0
Physical examination of ankles and foot/toes: Normal.Gait: Normal
Diagnosis: Headache Cervicalgia Myalgia Sprain of ligaments of cervical spine, subsequent encounter Sprain of joints and ligaments of other parts of neck, subsequent
encounter Sprain of ligaments of lumbar spine, subsequent encounter Spondylosis without myelopathy or radiculopathy, lumbosacral region Low back pain Sprain of ligaments of thoracic spine, subsequent encounter Contusion of bilateral shoulder, initial encounter Unspecified sprain of bilateral shoulder, initial encounter Sprain of unspecified site of bilateral knee, initial encounter Trochanteric bursitis right hip
Follow up evaluation in 3-4 weeks. Patient is totally disabled 100%.Work status:
Page 17 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Has the patient missed work because of the injury? Yes, 07/30/YYYY
Treatment and plan: Physical therapy re-evaluation and treatment 3 times per week Orthopedic consultation and/or follow up for bilateral shoulders/knees
Patient is referred for the following: MRI cervical and lumbar spine
PT referral:For cervical spine, bilateral shoulder, lumbar spine, bilateral hips and kneesModalities: HMP and ultrasoundProcedures: Passive and active ROM, neck/low back exercise, joint mobilizationTreatment plan: 3-4 times per week.
09/06/YYYY Hospital/Provider Name
MRI of the left shoulder:
Indication: Rotator cuff tear
Finding: There are no acute displaced fractures, dislocations, destructive bony
lesions or marrow infiltration in the proximal humerus and glenoid. There is a type III acromion with hypertrophic changes of the acromioclavicular joint with impingement of the rotator cuff in an appropriate clinical setting. There is bone marrow edema in the distal clavicle and adjacent acromion with fluid in the acromioclavicular joint, likely as a result of recent trauma, in an appropriate clinical setting.
The rotator cuff musculature including the supraspinatus, sub scapularis, infraspinatus and teres minor are normal in bulk without atrophy, edema or fatty infiltration. There is thickening with intrasubstance T2 signal of the distal supraspinatus tendon consistent with intrasubstance partial tear in combination with tendinosis/tendinopathy, in an appropriate clinical setting. The subscapularis, infraspinatus and teres minor tendons are intact without MRI evidence of a tear or tendinosis/tendinopathy. The biceps tendon is situated within the bicipital groove and its attachment to the superior labrum is intact. The glenoid labrum is grossly intact. There is no joint effusion. There are no masses or fluid collections associated with the glenohumeral joint.
Impression: Type III acromion with hypertrophic changes of the acromioclavicular
joint with impingement of the rotator cuff, in an appropriate clinical setting.
Bone marrow edema in the distal clavicle and adjacent acromion with fluid in the acromioclavicular joint, likely as a result of recent trauma, in an appropriate clinical setting.
Thickening with infrasubstance T2 signal of the distal supraspinatus tendon consistent with intrasubstance partial tear in combination with tendinosis/tendinopathy, in an appropriate clinical setting.
86
09/06/YYYY Hospital/Provider MRI of the left shoulder: 87
Page 18 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Name Indication: Rotator cuff tear
Findings: There are no acute displaced fractures, dislocations, destructive bony
lesions or marrow infiltration in the proximal humerus and glenoid. There is a low lying acromion with impingement of rotator cuff. There is bone marrow edema in the distal clavicle and adjacent acromion with fluid in the acromioclavicular joint likely as a result of recent trauma, in an appropriate clinical setting.
The rotator cuff musculature including the supraspinatus, subscapularis, infraspinatus and teres minor are normal in bulk without atrophy, edema or fatty infiltration. The rotator cuff tendons including the supraspinatus, subscapularis, infraspinatus and teres minor are intact without MRI evidence of a tear or tendinosis/tendinopathy. The biceps tendon is situated within the bicipital groove and its attachment to the superior labrum is intact. The glenoid labrum is grossly intact. There is no joint effusion. There are no masses or fluid collections associated with the glenohumeral joint.
Impression: Low lying acromion with impingement of rotator cuff. Bone marrow edema in the distal clavicle and adjacent acromion with
fluid in the acromioclavicular joint, likely as a result of recent trauma, in an appropriate clinical setting.
09/07/YYYY Hospital/Provider Name
Spinal ROM assessment:
Final impairment:WP spine impairment 42%WP left UE impairment 10%WP left LE impairment 11%WP right UE impairment 10%WP right LE impairment 11%Final whole person impairment 64%
MMT Left RightMax CV Valid Max CV Valid Deficit
Neck flexion 10 lb 0% YesNeck extension 8 lb 0% YesKnee extension 12 lb 0% Yes 13 lb 0% Yes -2%
LeftShoulder flexion 8 lb 0% Yes 9 lb 0% Yes -7%
LeftShoulder abduction 8 lb 0% Yes 8 lb 0% Yes -4%
LeftShoulder extension 8 lb 0% Yes 9 lb 0% Yes -1%
Left
187-197
Page 19 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Spine ROM Max Dev ValidCervical flexion 17° 3° YesCervical extension 17° 1° YesCervical left rotation 28° 3° YesCervical right rotation 27° 1° YesLumbar left lateral 8° 1° YesLumbar right lateral 9° 1°Lumbar minimum lordosis 26°Lumbar flexion 11° 1° YesLumbar extension 6° 2° YesSacral hip flexion 0° 0°Sacral hip extension 0° 0°
Extremity ROM Left RightShoulder internal rotation 14° 16°Shoulder external rotation 12° 11°Shoulder flexion 120° 115°Shoulder extension 11° 11°Shoulder adduction 18° 15°Shoulder abduction 118° 115°Knee flexion 78° 76°Knee extension 66° 66°
.10/03/YYYY Hospital/Provider
NameAcupuncture therapy final visit: (Illegible notes)
Subject: Complaint of neck pain, lower back pain, shoulder pain, left knee pain
Objective: Moderate
Pain level: 5-7/10
Assessment/plan:Treatment site: Neck, shoulder, lower back, hand, kneePain relief: Minimal, 36 gauge
Acupuncture points selected:
Procedure: 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
144
10/11/YYYY Hospital/Provider Name
Outcome assessment testing summary report:
Date of accident: 07/30/YYYY
Headache disability index:Current treatment result: The outcomes assessment summary demonstrates the
107-125
Page 20 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
current score compared to the previous score. A positive current change number on the outcomes assessment summary reflects health improvement from the previous assessment whereas a negative number reflects health worsening. A positive current change number greater than 28 reflects a positive treatment result (1).Subjective knee score questionnaire, NDI, Oswestry low back pain disability questionnaire, Roland Morris Disability Questionnaire, SPADI:Current treatment result: A positive current change number on the outcomes assessment summary reflects health improvement from the previous assessment whereas a negative number reflects health worsening.
10/15/YYYY Hospital/Provider Name
MRI of the cervical spine:
Indication: Disc herniation
Findings: There are no acute displaced fractures, dislocations, destructive bony
lesions or marrow infiltration. There is no listhesis. The Craniocervical relationship is preserved. The cervical spinal cord is normal in size and position. There is no paravertebral soft tissue swelling. There are no paravertebral masses or fluid collections. The Atlanto-axial joint is intact.
At C2-C3 level, the disc is normal in height and signal intensity without contour abnormalities, annular tears and without spinal or neural foraminal stenosis.
At C3-C4 level, there is normal disc space height with desiccation of the disc. There is a posterior central disc herniation with compression of anterior thecal sac and impingement of descending nerve roots and partial effacement of anterior subarachnoid space.
At C4-C5 level, there is normal disc space height with desiccation of the disc. There is a posterior central disc herniation with compression of anterior thecal sac and impingement of descending nerve roots and partial effacement of anterior subarachnoid space.
At C6-C7 level, there is normal disc space height with desiccation of the disc. There is a posterior central disc herniation with compression of anterior thecal sac and impingement of descending nerve roots and partial effacement of anterior subarachnoid space.
At C7-T1 level, the disc is normal in height and signal intensity without contour abnormalities, annular tears and without spinal or neural foraminal stenosis.
Impression: Posterior central C3-4 disc herniation with compression of anterior thecal
sac and impingement of descending nerve roots and partial effacement of anterior subarachnoid space.
C4-5 disc bulge with compression of anterior thecal sac and partial effacement of anterior subarachnoid space.
Posterior central C5-6 disc herniation with compression anterior thecal sac and impingement of descending nerve roots and partial effacement of anterior subarachnoid space.
C6-7 disc bulge with compression of anterior thecal sac and partial
82-83
Page 21 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
effacement of anterior subarachnoid space.10/15/YYYY Hospital/Provider
NameMRI of the cervical spine:
Indication: Disc herniation
Findings: There are no acute displaced fractures, dislocations, destructive bony
lesions or marrow infiltration. The bony alignment is intact. The spinal cord terminates appropriately. The cauda equina and the thecal sac are unremarkable without evidence of arachnoiditis. The visualized aorta is normal in course and caliber. There are no significant paravertebral soft tissue abnormalities.
At T12-L1, the disc is normal in height and signal intensity without contour abnormalities, annular tears and without spinal or neural foraminal stenosis.
At L1-L2, the disc is normal in height and signal intensity without contour abnormalities, annular tears and without spinal or neural foraminal stenosis.
At L2-L3, the disc is normal in height and signal intensity without contour abnormalities, annular tears and without spinal or neural foraminal stenosis.
At L3-L4, there is a diffuse disc bulge with encroachment on the neural foramina. There are no protrusions, sequestrations, annular tears or spinal stenosis. There is fluid in the facet joints.
At L4-L5, there is mild loss of disc space height with desiccation of the disc. There is a diffuse disc herniation with compression of anterior thecal sac and bilateral neural foramina and bilateral exiting nerve root. There are moderate facet and ligamentum hypertrophic changes with moderate spinal canal stenosis. There is fluid in the facet joints.
At L5-S1, there is diffuse disc bulge with encroachment of neural foramina. There are no protrusions, sequestrations or annular tears. There are moderate facet and ligamentum hypertrophic changes with moderate spinal canal stenosis. There is fluid in the facet joints.
Impression: At L3-L4, there is a diffuse disc bulge with encroachment on the neural
foramina. Mild loss of L4-L5 disc space with diffuse disc herniation with
compression of anterior thecal sac and bilateral neural foramina and bilateral exiting nerve root and moderate facet and ligamentum hypertrophic changes with moderate spinal canal stenosis.
L5-S1 disc bulge with encroachment of neural foramina and are moderate facet and ligamentum hypertrophic changes with moderate spinal canal stenosis.
Fluid in the facet joints at L3-4, L4-5 and L5-S1 which may be seen in a setting of flexion/hypertension injury or other trauma in an appropriate clinical setting. Correlate clinically.
84-85
11/22/YYYY-01/08/YYYY
Hospital/Provider Follow-up visit: 45-53,
Page 22 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Name Current treatment and procedures: Physical therapy Acupuncture chiropractic
Current complaints:Headache - BetterNeck pain – 2-5/10, intermittent and stiffness, radiating to fingersLow back pain 2-3/10, intermittent, sometimes 5-6/10 radiating to right buttock, left thigh, left leg occasionally6-7/10 Bilateral shoulder pain, radiating down the arm5-6/10 Bilateral knee pain and stiffness aggravated by walking and climbing stairs intermittent
Other:Since the accident the patient is: Full timePatient comes to the office: Car service
Physical examination:Patient is alert and orientedModerate pain and discomfortCervical, lumbar spine: Improved
Motor: No muscle atrophy noted. Motor muscle tests normal.DTRs: All normalSensory: Intact
Neck and cervical ROM Normal ROM Patient ROMFlexion 0-60 50 with painExtension 0-50 35 with painRight rotation 0-80 60 with painLeft rotation 0-80 60 with painRight lateral flexion 0-45 40 with painLeft lateral flexion 0-45 40 with pain
There is tenderness to palpation with muscle spasm at right and left C3, 4, 5, 6, 7 paraspinals, bilateral trapezius, bilateral rhomboid.
Examination of bilateral shoulders: Better but sometimes 5-6/10Bilateral shoulders Normal ROM Right LeftForward flexion 0-180 180 180Backward extension 0-50 50 50Adduction 0-45 45 45Abduction 0-180 130 160Internal rotation 0-80 80 80External rotation 0-70 70 70
There was mild to moderate pain/tenderness at right/left
63-71
Page 23 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
There is tenderness of bilateral trapezius and bilateral both supraspinatus, infraspinatus bilateral, bilateral bicipital tendon.Impingement test negative
Examination of bilateral thoracic spine: Better. 3/10. Anterior chest wall.
Elbow, wrist, hand, thumb, hips, ankles, foot/toes: WNL
Examination of lumbar spine:No muscle spasm and no scar or deformityThere was tenderness at the lumbar paraspinal muscles at L L S1 right/leftLumbar paraspinals are mildly/moderately spastic on the right/left/both sideSpasms of lumbar paravertebral muscles form L1, L2, L3, L4, L5, S1 disc space right/leftActive trigger points noted on left facet right/left SIJ right/left gluteus medius.Reactive spasms of left piriformis muscles.SLR positive on both sides, left 45°.
Lumbar spine Normal ROM ExamFlexion 0-60 40 with painExtension 0-30 20 with painRight rotation 0-45 40 with painLeft rotation 0-45 40 with painRight lateral flexion 0-30 25 with painLeft lateral flexion 0-30 25 with pain
Physical examination of bilateral knee:There was pain on motion on active and passive mobilization in right and left.McMurray test, Lachman’s, patella grinding test, anterior/posterior Drawer test was negative.Distal vascular status is normal.There is tenderness to palpation on medial/lateral aspect of the midline joint on the right and left knee.
ROM of bilateral knees is moderately restricted in all directions secondary to pain. It is as follows:
ROM Normal Right LeftForward 0-135 130 130Extension 0-0 0 0
Gait: Normal
Diagnosis: Cervicalgia Myalgia Sprain of ligaments of cervical spine, subsequent encounter Sprain of joints and ligaments of other parts of neck, subsequent
Page 24 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
encounter Sprain of ligaments of lumbar spine, subsequent encounter Spondylosis without myelopathy or radiculopathy, lumbosacral region Low back pain contusion of unspecified front wall of thorax, subsequent encounter Sprain of ligaments of thoracic spine, subsequent encounter Contusion of bilateral shoulder, subsequent encounter Unspecified sprain of bilateral shoulder, subsequent encounter Sprain of unspecified site of bilateral knee, subsequent encounter Trochanteric bursitis right hip
Follow up:Follow up evaluation in 3-4 weeksDisability: Moderate 50-74%Work status:Has the patient missed work because of the injury? Yes, 07/30/YYYY
Treatment and plan: Physical therapy re-evaluation and treatment 2-3 times per week
01/25/YYYY Hospital/Provider Name
Spinal ROM assessment:
Final impairment:WP spine impairment 32%WP left UE impairment 7%WP left LE impairment 8%WP right UE impairment 7%WP right LE impairment 8%Final whole person impairment 50%
MMT Left RightMax CV Valid Max CV Valid Deficit
Neck flexion 15 lb 0% YesNeck extension 12 lb 0% YesKnee extension 16 lb 0% Yes 16 lb 0% Yes -1%
LeftShoulder flexion 13 lb 0% Yes 13 lb 0% Yes -1%
RightShoulder abduction 13 lb 0% Yes 13 lb 0% Yes -1%
LeftShoulder extension 13 lb 0% Yes 13 lb 0% Yes -1%
Right
Spine ROM Max Dev ValidCervical flexion 26° 2 YesCervical extension 28 3 YesCervical left rotation 35 3 YesCervical right rotation 33 3 Yes
154-164
Page 25 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Lumbar left lateral 12 2 YesLumbar right lateral 12 2Lumbar minimum lordosis 33Lumbar flexion 19° 1° YesLumbar extension 13° 2° YesSacral hip flexion 0° 0°Sacral hip extension 0° 0°
Extremity ROM Left RightShoulder internal rotation 32 29Shoulder external rotation 27 23Shoulder flexion 140 138Shoulder extension 21 19Shoulder adduction 24 21Shoulder abduction 144 139Knee flexion 99 96Knee extension 88 83
.02/14/YYYY Hospital/Provider
NamePhysical therapy final evaluation:
Patient complains of pain on neck, bilateral shoulder, back and bilateral knees
PT modalities: Moist heat, electrical stimulation, active exercise
Remarks: Patient tolerated well
128
03/29/YYYY Hospital/Provider Name
Spinal ROM assessment:
Final impairment:WP spine impairment 25%WP left UE impairment 4%WP left LE impairment 4%WP right UE impairment 4%WP right LE impairment 6%Final whole person impairment 38%
MMT Left RightMax CV Valid Max CV Valid Deficit
Neck flexion 20 lb 0% YesNeck extension 16 lb 0% YesKnee extension 24 lb 0% Yes 25 lb 0% Yes -2%
LeftShoulder flexion 18 lb 0% Yes 17 lb 0% Yes -3%
RightShoulder abduction 17 lb 0% Yes 17 lb 0% YesShoulder extension 17 lb 0% Yes 18 lb 0% Yes -3%
Left
165-175
Page 26 of 27
Patient Name DOB: 02/01/YYYY
DATE FACILITY/ PROVIDER
MEDICAL EVENTS PDF REF
Spine ROM Max Dev ValidCervical flexion 39 2 YesCervical extension 39 1 YesCervical left rotation 46 1 YesCervical right rotation 18 2 YesLumbar left lateral 19 2 YesLumbar right lateral 19 2Lumbar minimum lordosis 39Lumbar flexion 25 2° YesLumbar extension 19 2° YesSacral hip flexion 0° 0°Sacral hip extension 0° 0°
Extremity ROM Left RightShoulder internal rotation 38 40Shoulder external rotation 33 36Shoulder flexion 155 157Shoulder extension 25 29Shoulder adduction 39 35Shoulder abduction 163 159Knee flexion 123 118Knee extension 99 96
.Other records: Correspondence, patient information, others, flow sheets, treatment sheets
Pg. Ref: 1-5, 21, 39, 152-153
*Comments: All the significant details are included in the chronology. These records have been reviewed and do not contain any significant information. Hence not elaborated.
Page 27 of 27
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