Sample Name: Chiropractic Initial Evaluation - 2
Description: Chiropractic Evaluation for neck and low back pain following a car accident.
(Medical Transcription Sample Report)
The patient presents today with neck and low back pain following a car accident on January 19, 2004. The patient was a driver in a midsize car when he was hit behind by a vehicle traveling about 30 miles per hour. His head was rotated to the right and he stated he saw the collision coming and braced appropriately. The impact caused his head to slam into his headrest, knocking off his hat. He was not rendered unconscious but was shaken and disoriented. He did not receive medical attention at the scene of the accident.
SUBJECTIVE COMPLAINTS: Constant pain in the bilateral regions of the neck increased by forward movement rotating laterally, bending the neck. He also has pain and tightness in his low back increased on the left. His pain level is 7/10. He also states that since the accident, he has experienced tension headaches that began in the suboccipital region referring to the top of his head. He has also experienced anxiety and nervousness.
PHYSICAL EXAMINATION: Height is 5'10". Weight is 270 pounds.
Visual Evaluation: The patient has anterior head carriage with rounded shoulders. He does not seem to be in any extreme distress. He has slight antalgic head position to the right.
Dynamometer Testing (grip strength) in pounds: The patient is right hand dominant. Right hand 110, 105, and 98. Left hand 80, 70, and 85.
Cervical spine range of motion:
Flexion 50/50 with moderate discomfort on the left.
Extension 50/60 with moderate discomfort on the left.
Right lateral bending 40/45 with moderate discomfort on the left.
Left lateral bending 40/45 with moderate discomfort on the right.
Right rotation 70/80 with moderate pain in the left.
Left rotation 70/80 with moderate pain in the left.
Lumbosacral range of motion:
Right lateral bending 25/25.
Left lateral bending 25/25 with pain in the left.
Right rotation 30/30 with moderate discomfort in the right.
Left rotation 30/30.
Orthopedic Tests: Axial compression negative with moderate pain bilaterally. Shoulder distraction negative with moderate pain bilaterally. Maigne's test negative bilaterally. Valsalva normal and swallow test normal. Heel walk normal. Toe walk normal. Sitting root normal. SLR normal. Patrick-Faber's normal. Iliac compression caused moderate pain in the left.
RADIOLOGY FINDINGS: X-rays of the cervical and lumbar will be taken today.
1. Cervical spine sprain/strain.
2. Lumbar spine sprain/strain.
3. Tension headaches.
CAUSATION: The patient's symptoms appeared to have come on as a result of the motor vehicle accident consistent with the one described in this report. His history, subjective, and objective findings show evidence from a medical viewpoint that his condition is due to the current injury only and no contributing factors are present from preexisting conditions. The patient's condition is a result of a bony/soft tissue injury that has resulted in an undetermined impairment at this time.
PROGNOSIS: The likelihood of nearly complete symptomatic relief within 90 days is excellent. The patient should reach maximum medical improvement in three or four months.
TREATMENT/PLAN: After completing an initial examination evaluation, I have selected the plan of treatment that should return this patient to a pre-injury status and minimize the possibility of future residuals. Treatment will consist of chiropractic manipulation, chiropractic physical therapy, and observation, decreasing in frequency as the patient's condition allows. I feel it is too early to determine whether this patient will have any residuals or permanent disability.
Keywords: chiropractic, neck, extension, cervical spine, dynamometer testing, flexion, heel walk, iliac compression, lumbosacral, maigne's, motor strength, patrick-faber's, sitting root, toe walk, valsalva, accident, antalgic, bending, grip strength, low back pain, pain, range of motion, rotation, tightness, spine sprain/strain, lateral bending, moderate discomfort, moderate, discomfort,