SYNERGY WELLNESS CLINIC

138 NE 2^nd AVE #300 MIAMI, FL 33132

Office (305) 371 – 5775 Fax (305) 675 – 5797

www.synergywellnessclinic.com

PAST MEDICAL HISTORY

Fulano De Tal / Joe Schmoe stated that he was involved in a motor vehicle accident on March 19, 2010, he injured his neck, received treatment, and his symptoms were resolved. Fulano De Tal / Joe Schmoe stated that he was pain free with regard to his symptoms of initial chief complaint prior to the accident in question. He denied any previous fracture or loss of consciousness.

FAMILY HISTORY

Unremarkable

MEDICATIONS / SUPPLEMENTS

He takes Advil for pain as needed.

SURGERIES / HOSPITALIZATION

He denied ever having had any major surgical procedures performed.

ALLERGIES

He denied having had any known allergies.

LIFESTYLE

He denied consuming any tobacco or caffeine. He occasionally drinks beer socially. He denied being engaged on any regular physical activity.

HISTORY OF CLINICAL PRESENTATION (CHIEF COMPLAINTS)

• Intermittent, sharp at times, dull at other times, cramping, moderate, neck pain that worsens with prolonged sitting.
• Intermittent, dull, cramping, burning, moderate mid back pain.
• Intermittent, dull, cramping, burning, moderate low back pain that worsens with prolonged sitting, driving, standing, walking, bending forward, and squatting

PHYSICAL EXAMINATION

A final physical examination was performed on December 8, 2010 and revealed a 30-year-old Italian male with an overweight morphology. His left brachial blood pressure was 120/80. He stood at 5 feet 11 inches and weighed 190 pounds. His respiration was 14 breaths per minute. His pulse was at 70 beats per minute. He was alert and oriented times three. The examinee stood up from the lobby chair and got on and off the exam table without difficulty.

Visual inspection of the cervicothoracic spine revealed no evidence of bleeding, bruising, tattoos, inflammation, or scars. Active cervicothoracic range of motion was limited and painful in all ranges. Digital palpation of the cervicothoracic spine revealed bilateral +1 tenderness from C1-T7 with moderate hypertonicity of the right paravertebral musculature from C1-T7.

Visual inspection of the lumbosacral spine revealed no evidence of bleeding, bruising, tattoos, inflammation, or scars with evidence of visible spasms in the paravertebral musculature. Active lumbosacral range of motion was painful and restricted in all ranges. Digital palpation of the lumbar spine revealed tenderness from L1-L5 with spasms palpable bilaterally from L1-S/15.

ORTHOPEDIC EXAMINATION

CERVICOTHORACIC

Axial Compression -+ Right – Left / Bilateral

Foraminal Compression -+ Right – Left / Bilateral

Shoulder Depressor -+ Right – Left / Bilateral

Soto Hall -+ Right – Left / Bilateral

Axial Distraction -+ Right – Left / Bilateral

George’s -+ Right – Left / Bilateral

Adam’s Negative

Valsalva’s Negative

Swivel Test Negative

Spinal Percussion - + at T6

LUMBOSACRAL

Kemp’s -+ Right – Left / Bilateral

Straight Leg Raise -+ Right – Left / Bilateral

Braggard’s -+ Right – Left / Bilateral

Yeoman’s -+ Right – Left / Bilateral

Valsalva’s -+ Right – Left / Bilateral

NEUROLOGICAL EXAMINATION

DERMATOMES MYOTOMES

LEVELS	LEFT	RIGHT	LEFT	RIGHT
C5	Hypoesthesia	Hyperesthesia	5/5 w/pain	5/5
C6	NORMAL	NORMAL	5/5	5/5
C7	NORMAL	NORMAL	5/5	5/5
C8	NORMAL	NORMAL	5/5	5/5
T1	NORMAL	NORMAL	5/5	5/5
L1	NORMAL	NORMAL	5/5	5/5
L2	NORMAL	NORMAL	5/5	5/5
L3	NORMAL	NORMAL	5/5	5/5
L4	NORMAL	NORMAL	5/5	5/5
L5	NORMAL	NORMAL	5/5	5/5
S1	NORMAL	NORMAL	5/5	5/5

Deep Tendon Reflexes: Left Right

Biceps +2 +2

Triceps +2 +2

Achilles +2 +2

Patella +2 +2

Pathological Reflexes:

Babinski Absent

DIAGNOSTIC / CLINICAL STUDIES

Fulano De Tal / Joe Schmoe was referred for an MRI of the lumbar spine that was performed on 01/09/2011 at Stand Up MRI Of Miami. Jonathan Eugenio, M.D. and Sean Mahan, M.D. had the following impressions:

• There is a loss of the normal lordotic curvature of the lumbar spine. In the correct clinical setting, this may reflect strain. Clinical correlation is recommended.
• Disc bulge at the level of L4-5 with anterior impression on the thecal sac.
• Disc bulge, desiccation, and osteophytes with disc space narrowing at the level of L5

TREATMENT RENDERED

This patient has been treated in this office for the purpose of reducing acute symptomatology, stabilizing and rehabilitating the areas of injury as well as attempting to minimize permanent impairment and disability. Treatment consisted of conservative chiropractic manipulative care, supplemented by physical therapy and rehabilitative stretches and exercises. Chiropractic manipulative care was used to restore proper vertebral motion in order to reduce irritation of spinal nerves, decrease muscular hypertonicity, and reduce pain. The physiotherapy included electrical muscle stimulation, heat, ice, ultrasound, massage therapy.

Electrical muscle stimulation was used to relax the hypertonicity of the musculature that was injured and or surrounding the injured joint. It was also used as an analgesic. Heat was used as a local, superficial hyperthermal effect on the body to increase the temperature in the body for vasodilatation and an analgesic effect and resulting in a calming effect, soft tissue relaxation and reduction of muscular spasm. Cold was used initially as a local, superficial hypothermal effect on the body to cool body tissue thereby decreasing tissue metabolism, causing vasoconstriction, reducing inflammation, and creating analgesia.

Ultrasound was used as a local, superficial hyperthermal effect on the tissues. It tends to cause vasodilatation of the blood vessels to bring more nutrients to the region. The ultrasound waves break up calcium deposition to prevent excess adhesion formation. This modality was performed at 1.5 joules per centimeters squared. Deep muscle trigger point therapy was utilized (ischemic compression of the trigger points) to reduce or relieve local spasms (trigger points), improve the functional capacity of the area involved, reduce pain, improve circulation to injured areas of the body, and remove cellular metabolic waste from the interstitial environment.

The rehabilitation of injured areas was the active component of the whole healthcare experience. It consisted of strengthening first the core stabilization muscles that naturally weaken as a result of inactivity. Then the focus shifted to the rest of the supporting musculature around the injured areas. It also consisted of first demonstrating and then supervising the self-stretching of their hypertonic muscles.

FUNCTIONAL ASSESSMENT INSTRUMENTS

In order to evaluate the functional assessment of the cervical spine, the Neck Disability Index was used, which is widely accepted and has documented reliability and validity. She scored 32 out of 100. She had pain symptoms with normal activity.

In order to evaluate the functional assessment of the lumbar spine, the Oswestry Disability Index 2.0 was used, which is widely accepted and has documented reliability and validity. She scored 70 out of 100. She had pain symptoms with normal activity.

The Lower Extremity Functional Scale was used in order to evaluate the functional assessment of her lower extremity. She scored 11 out of 80, which is a clinically meaningful functional change [according to Binkley JA, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): Scale Development, Measurement Properties, and Clinical Application. Physical Therapy (1999) 79, 371-383.]

ADDITONAL TREATMENT

Further treatment will be utilized to accelerate the restoration of vertebral physiological motion, and therapeutic exercises have been prescribed for this patient designed to strengthen an increase the endurance of specific muscles that have been weakened and injured in this accident. It is my professional opinion based upon the findings of my examination procedures, as well as similar cases I’ve had in the past, that Fulano De Tal / Joe Schmoe will require approximately $1,200 per year ($100 per month) in palliative treatment. This will allow him to function as close to normal as possible with regard to his activities of daily living.

DIAGNOSES

1. Post-traumatic Cervical Sprain/Strain
2. Cervical Radiculopathy
3. Post traumatic Thoracic Sprain / Strain
4. Post-traumatic Lumbar Sprain/Strain
5. Lumbar Radiculopathy
6. Rotator Cuff Syndrome
7. Medial Collateral Ligament partial tear of the left knee
8. Right / Left Shoulder and Upper Arm Sprain / Strain
9. Right / Left Elbow and Forearm Sprain / Strain
10. Right / Left Wrist Sprain / Strain
11. Right / Left Hand Sprain / Strain
12. Right / Left Hip and Thigh Sprain / Strain
13. Right / Left Knee Sprain / Strain
14. Right / Left Ankle Sprain / Strain
15. Right / Left Foot Sprain / Strain
16. Myalgia and Myositis

PROGNOSIS

Due to the nature of this condition and because of our findings upon examination and evaluation, the prognosis in this case must be considered guarded. He still is exhibiting palpable tenderness and trigger points over the cervical and lumbar regions, with associated limited ranges of motion.

DISCUSSION

In this traumatic injury to the cervical and lumbar regions, it seems probable that there has been traumatic insult to the anterior and posterior longitudinal ligaments and accessory spinal ligaments. Nerve compression has caused intermittent radicular pain that causes muscles supporting the injured area to go into spasm. This results in a higher likelihood of further aggravation and re-injury in the future.

His condition has improved over time however he still demonstrates residual complaints and symptomatology regarding his neck and low back. Therefore, in the future he will be subject to episodes of exacerbation caused by various types of aggravation.

Lifting, bending and repetitive movements such as lifting over his head will cause aggravation to his injured areas. It is my professional opinion resulting from my examination procedures as well as my experience with similar cases, that this weakness, particularly in the cervical region, increases his predisposition to future injury and trauma. He was asymptomatic prior to the accident in question. Therefore, it is my professional opinion that the regional symptomatology he is experiencing now is a direct result of the accident in question.

This patient has reach maximum chiropractic improvement and further care will only be palliative and not corrective in nature. He had difficulty with regards to pushing, pulling and lifting. He is not capable of producing or performing select activities relating to recreation at this point.

Fulano De Tal / Joe Schmoe has been advised to call this office to arrange for treatment of a supportive and a palliative nature if significant episodes of discomfort and/or pain occur, or if his condition worsens. At this time, the patient has been removed from a regular regimen of treatment. It is very likely, however, that treatment may be needed from time to time in the future.

IMPAIRMENT RATING

The following impairment rating has been given to Fulano De Tal / Joe Schmoe after an orthopedic and neurological final examination performed on June 7, 2006. It is my opinion that this patient has reached the point of maximal medical improvement under my care.

CATEGORY 1

It is also my opinion that this patient has sustained a 2% permanent physical impairment of the body as a whole. This impairment rating is based upon continued pain in the cervical and lumbar spine but with no significant clinical findings or spasms / muscle guarding. This impairment falls into the diagnosis related estimate category 1 in the 2000, 5^th edition of the AMA Guides to the Evaluation of Permanent Impairment.

CATEGORY 2

It is also my opinion that this patient has sustained a 10% permanent physical impairment of the body as a whole. This impairment rating is based upon continued pain in the cervical and lumbar spine, muscle spasms at the time of the exam, asymmetric loss of range of motion, and non-verifiable radicular complaints / radicular complaints of the right upper extremity. This impairment falls into the diagnosis related estimate category 2 in the 2000, 5^th edition of the AMA Guides to the Evaluation of Permanent Impairment.

CATEGORY 3

It is also my opinion that this patient has sustained a 28% permanent physical impairment of the body as a whole. This impairment rating is based upon continued pain in the cervical and lumbar spine, sensory loss in dermatome distribution, loss of relevant reflexes, loss of muscle strength, muscle spasms at the time of the exam, posterior element fracture with displacement disrupting the spinal canal, asymmetric loss of range of motion, and herniated nucleus pulposus (HNP) with radicular complaints of the right upper extremity. This impairment falls into the diagnosis related estimate category 3 in the 2000, 5^th edition of the AMA Guides to the Evaluation of Permanent Impairment.

CAUSALITY STATEMENT

Fulano De Tal / Joe Schmoe denied any subsequent injury or trauma between the date and time of accident in question and when he showed up to my office. Based on the history of clinical presentation and physical examination findings, it appears that there is a causal relationship between the injuries in which he presented to me and the motor vehicle accident in question. His prior cervical injury will be apportioned below. The possibility of any other accident or traumatic event as the cause to this patient’s injuries can be excluded for the moment.

APPORTIONMENT

There is a clinical need to further evaluate Fulano De Tal / Joe Schmoe’s cervical symptoms to determine if the history of clinical presentation is an aggravation or an exacerbation of his prior cervical spine injury from the 2010 motor vehicle accident. Medical records from the treatment of his prior cervical injury will be ordered to determine a baseline. An MRI is the initial diagnostic study of choice to determine the differentiation. If the MRI shows positive findings, which may present a medical necessity for further evaluation, then other diagnostic studies may be ordered depending on the clinical presentation after the first phase of treatment.

RECOMMENDATION

It is my opinion at this time that there is no reason to expect any major change in Fulano De Tal / Joe Schmoe clinical picture in the immediate future. It is my recommendation that he only return to this office for supportive and therapeutic care only on an emergency or as – needed basis.

I have advised the patient to continue hot shower and to use moist hot compresses for his neck, low back as well as continued home stretching and exercise. I have also advised him to take over the counter preparations to help relieve some of his pain. This patient should avoid any and all lifting above 20lbs. and should avoid situations that require prolonged bending, squatting, stooping, standing or sitting.

If you have any further question regarding this file, please do not hesitate to contact my office at any time.

Professionally submitted,

Gustavo Marshall, D.C.

Chiropractic Physician

FL DOH License #CH8807