FINAL MEDICAL REPORT
To whom it may concern:
The following is our medical report on Lance Smith who originally sought medical treatment at this office on 1/4/2018 relative to injuries he sustained as the result of an automobile accident, which took place on 1/1/2018. At the time of his first visit to this office Mr. Smith underwent a comprehensive history and physical examination. The findings of that examination and his subsequent course of treatment follow
Additional information concerning this injury are contained in your files.
At the time of Mr. Smith’s initial visit to this office on 1/4/2018, He was a 29 year old male, 6’ 2” tall, weighing 190 pounds in apparent distress and complained of the following areas of pain and discomfort: Neck, left shoulder, right elbow, right hand, left thigh, left leg and back.
Mr. Smith stated that on the day of the accident he was the driver of his Ford F-150 pick-up truck traveling North on Pacific Coast Highway in Malibu when a GMC Yukon traveling North on Pacific Coast Highway made a sudden unexpected U-Turn directly in front of him. Unable to stop in time he impacted the vehicle. He was wearing a seat belt and his air bags deployed causing him to be jolted, pitched and thrown around in the vehicle. He did not lose consciousness.
Following the accident, Mr. Smith stated that he was dazed, shocked, shaky, lightheaded, jittery, nervous, and confused. He stated that he immediately developed pain and muscle spasms in his neck and back. He refused emergency treatment at the scene by the paramedics and tried treating himself with hot showers, rest and over the counter medication, but the pain didn’t go away and on 1/4/2019 he presented himself at this office for examination and treatment of his injuries.
REVIEW OF SYSTEMS
Prior to this injury Mr. Smith most current and usual weight was 190 pounds and there have been no recent weight changes. He denied weakness, fatigue, and or fever.
There was no history of rashes, lumps, itching, dryness, color changes or changes in the hair or nails.
Mr. Smith denied prior history of headaches or head trauma.
There had been no lumps or history of goiter.
Mr. Smith was without prior history of cough, sputum production, wheezing, asthma, bronchitis, emphysema, recurrent pneumonia or history of tuberculosis.
There was no history of claudication, varicose veins, or thrombophlebitis.
Mr. Smith was without prior history of nausea, vomiting, diarrhea, constipation, belching, bloating, hematemesis, dysphagia, heartburn, indigestion, abdominal pain, peptic ulcer, jaundice, and/or gallbladder disease. The liver was without history of hepatitis. There was no melena, bright red blood per rectum or history of hemorrhoids.
There had been no prior history of frequency, polyuria, nocturia, dysuria, hematuria, urgency, hesitancy, incontinence, urinary tract infections, or kidney stones.
There was no prior history of arthritis or gout.
Mr. Smith denied any history of anemia, easy bruising, blood dyscrasias or history of transfusion.
There was no history of diabetes, thyroid problems, hot or cold intolerance, polydypsia, or excessive sweating.
There had been no prior history of seizure disorders, CVA, TIA or history of meningitis.
Mr. Smith denied prior history of nervousness, tension, mood disorder, or depression.
Mr. Smith has had no prior history of discharge, venereal disease, reproductive organ pain, or problems with sexual difficulties.
Mr. Smith stated the he has no allergies.
DEVELOPMENT AND SOCIAL HISTORY
Mr. Smith does not smoke cigarettes, never drinks alcohol, and is single.
FAMILY MEDICAL BACKGROUND
His family history in noncontributory to this condition.
PAST MEDICAL HISTORY
Mr. Smith confirmed that he enjoyed generally good health prior to the aforementioned accident. Other accidents, illnesses, surgeries, and traumas were denied.
A complete detailed physical examination was performed on the neck, back, upper and lower extremities
Mr. Smith’s movements were guarded and he was able to walk guarding his left leg. He seemed to be alert. This 29 year old male appeared to be his reported age and was normally developed. He was right handed, 6’ 2” tall and weighed 190 pounds. His blood pressure was 145/80 and he appeared to be in acute distress due to his pain. Mr. Smith’s posture was affected.
Normocephalic, atraumatic. No sign of tenderness or external injury was evident. Mr. Smith was not complaining of headaches.
The pupils were equal, round and reactive. Extraocular movements were normal. Peripheral vision was normal.
The ear canals and tympanic membranes were clear with no evidence of excessive crumen of scarring. The nasal passages were clear and free of discharge. The tongue was midline and the oral cavity revealed no evidence of dental trauma or loosening of the teeth.
The cervical spine region was painful when palpated from C1 through C7. This pain was accompanied by tenderness and spasm of the anterior, posterior, and bilateral muscle of the neck. Range of motion was acutely restricted due to this pain. Auscultation of the carotid arteries appeared to be normal.
ACTIVE CERVICAL RANGE OF MOTION
|Flexion||90||45||pain and spasm |
|Extension||30||15||pain and spasm |
|Left Rot.||30||20||pain and spasm |
|Right Rot.||30||15||pain and spasm |
|L. Lat Flex.||20||10||pain and spasm |
|R. Lat Flex.||20||05||pain and spasm |
Century West Chiropractic
1990 Westwood Blvd., Suite 110
Los Angeles, CA 90025
D.C., Q.M.E., D.A.B.D.A.
Fax: (310) 475-3574
There was a 4” x 4” contusion with abrasion over the anterior portion of the left thigh. He complained of left shoulder, right elbow, right hand, left thigh and left leg affecting his gait. Shoulder, elbow and wrist motions were satisfactory. Hip, knee, and ankle motions were also satisfactory. There was no evidence of bone injury or muscle atrophy.
There was no evidence of deformity, atrophy, infection, or inflammation. The shoulder girdles were symmetrical. There was palpable tenderness over the deltoid and glenohumeral joints. There was no crepitations during range of motion.
EXTREMITIES CIRCUMFERENTIAL MEASUREMENTS:
Dr. Jayson I. Sher
D.C., Q.M.E., D.A.B.D.A
DR. JAYSON I. SHER
Clarence Darrow Attorney
21345 Wilshire Blvd., Suite 2013
Los Angeles, CA 90023
Patient Name: Smith, Lance
Accident Date: 1/1/20018
Date of Birth: 11/11/1982
Date of Examination: 1/4/2018
ORTHOPEDIC AND NEUROLOGICAL EXAMINATION
An Orthopedic and Neurological examination was performed and the results were as follows:
Foramina Compression Test was positive.
Shoulder depression Test was positive on the left.
Soto Halls Test was positive.
Lassegue’s Test was positive bilaterally.
Braggard’s Test was positive bilaterally.
Bilateral Leg Lower Test was positive.
Ely’s Test was positive bilaterally.
Neurological examination revealed:
Peripheral sensitivity was tested using a Wharton Pinwheel, the results were as follows:
Negative right C6, C7 and L2.
Negative left L4 and L5.
Mr. Smith was alert, responsive, and well orientated to person, place, and time throughout the examination
CRANIAL NERVE EXAMINATION
Olfactory: negative Facial: negative
Optic: negative Auditory: negative
Occulomotor: negative Glossopharyngeal: negative
Trigeminal: negative Vagus: negative
Trochlear: negative Accessory: negative
Abducens: negative Hypoglossal: negative
DEEP TENDON REFLEXES
Deep tendon reflexes were normally exhibited bilaterally in the biceps, triceps, brachioradialis, right patella, and Babinski.
Coordination testing showed finger-nose-finger, heel-knee-shin, and rapid alternating movements of the feet and hands to be all normal. No rebound phenomena of pendular reflexes were noted.
X-RAY & MRI SCAN RESULTS
On 1/4/2012 cervical and lumbar x-rays were ordered to rule out bony pathology the results were as follows;
Cervical Spine: Complete loss of the normal lordotic curvature with interruptions at C4, C5 and C6. Negative for recent fracture and or complete dislocation.
Lumbar Spine: Marked decrease in the L5 – S1 intervertebral disc space.
MRI results were as follows:
The L4 – L5 disc shows desiccative changes with diffuse 2-3 mm bulging. No nerve root compression or displacement is seen.
The L5-S1 disc shows desiccative changes with diffuse 4-5 mm bulging causing effacement of the ventral surface of the thecal sac very close to the exiting S1 nerve roots. Irritation of these roots cannot be excluded and clinical correlation is requested in this regard.
Based on the physical examination and special studies findings, the following diagnosis was concluded:
Cervical myoligamentous sprain/strain injury with radiculitis radiating into the left shoulder and myospasm and myalgia of the cervical musculature.
Thoracic sprain/strain injury with paravertebral myospasm and myalgia.
Lumbar Lumbosacral sprain/strain injury with left sciatic radiculitis radiating into the left thigh and leg, a 4-5mm L5-S1 disc bulging causing effacement of the ventral surface of the thecal sac very close to the exiting S1 nerve roots and bilateral paravertebral myospasm and myalgia.
Trauma injury to the left shoulder.
Trauma injury to the right hand.
Trauma injury with a 4” x 4” abrasion to the anterior aspect of the left thigh.
EVALUATION SUMMARY REGIME
Mr. Smith was place on disability form 1/4/2018 through 3/12/2018 due to the requirements of his work, his pain and the decreased mobility due to muscle spasm and pain. He was immediately started on a course of Chiropractic treatment of specific bony manipulation to correct interosseous disrelationships with general spine mobilization maneuvers and the application of hot packs, electrical stimulation, ultrasound and when necessary and massage (all of which are itemized in the patient's final statement). In order to lower the cost of treatment, the patient may have also received certain services which will not be included in the final bill. These services are re-evaluations by the doctor on every visit, manuel traction as well as the application of heat and cold packs, gentle stretching, analgesics, postural instruction and rehabilitation exercises to reduce the severity of the muscle spasm wnich often hinder the effectiveness of the spinal manipulations and can retard the healing process.
Mr. Smith was noted to garner the benefits from his treatment and when last seen for treatment in this office on 4/3/2018 he had complaints of intermittent neck and back discomfort. He has not returned since that visit and was discharged as of that date with a guarded prognosis.
The examination portion of this medical report was typed by me on 1/11/2018, saved to the computer, and completed after his discharge.
On 6/1/2018 Mr. Smith returned to this office complaining of increased back pain and stiffness. He stated that his job requires moderate to heavy lifting, prolonged standing and driving. Which since returning to work after this injury all tend to cause his back to hurt by the end of the day. He was again started on a treatment program of therapy and manipulations. He was also instructed in the necessity for him to perform stretching warm up exercised prior to lifting in order to increase blood supply to the once injured area.
Regarding sprain/strain injuries to the axial skeleton especially with confirmed disc protrusion the prognosis must remain guarded as exacerbations and remissions are common and may be provoked by ordinary activities of daily living. These injuries heal slowly, poorly, and many times incompletely. This is due to poor blood supply of the ligaments and fibrous tissues.
He received six more treatments and on his final treatment of 6/20/2018, I felt he had received the maximum benefits from his treatment and he was discharged as of that date with a guarded prognosis.
If we can be of further assistance to you with reference to this patient, please feel free to contact this office at any time.
Very truly yours,
Jayson I. Sher, D.C., Q.M.E., D.A.B.D.A.