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Patient Name DOB: 02/01/YYYY

Medical Chronology/Summary

Confidential and privileged information

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*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.

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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.

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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

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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.

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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


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

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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

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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.

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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

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Office visit for initial comprehensive examination:

Date of loss: 07/30/YYYY

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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

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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.

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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

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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

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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

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*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


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.

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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

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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

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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

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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.


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

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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:


Current treatment and procedures: Physical therapy Acupuncture chiropractic

Current complaints:Disturbed sleepHeadache. dizziness

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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.

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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:

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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.


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.

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09/06/YYYY Hospital/Provider MRI of the left shoulder: 87

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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.


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



LeftShoulder abduction 8 lb 0% Yes 8 lb 0% Yes -4%

LeftShoulder extension 8 lb 0% Yes 9 lb 0% Yes -1%

Left

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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°


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


Outcome assessment testing summary report:


Headache disability index:Current treatment result: The outcomes assessment summary demonstrates the

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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.


MRI of the cervical spine:

Indication: Disc herniation


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 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

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effacement of anterior subarachnoid space.10/15/YYYY Hospital/Provider

NameMRI of the cervical spine:

Indication: Disc herniation


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.

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11/22/YYYY-01/08/YYYY

Hospital/Provider Follow-up visit: 45-53,

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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

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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

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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







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

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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


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







RightShoulder abduction 17 lb 0% Yes 17 lb 0% YesShoulder extension 17 lb 0% Yes 18 lb 0% Yes -3%

Left

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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.

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