· Web viewAll the medical details have been included “word by word’ or “as it is” from the ... Sprain of ligaments of cervical spine. Dorsalgia. Upper and mid back pain

Patient Name DOB: 03/14/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 has 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 07/05/YYYY, the injuries and

clinical condition of XXXX as a result of accident, treatments rendered for the complaints and 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.

Prior visits for other medical conditions have been included in brief for reference.

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Injury Report:

DESCRIPTION DETAILSPrior injury details No prior injury Date of injury 07/05/YYYYDescription of injury

Patient was not helmeted driver and heading east on Bridge street at 20 mph when her motorcycle was struck by a car from front which was headed to west on Bridge street resulted in collision.

Injuries/Diagnoses Acute post-traumatic headache Cervicalgia Sprain of ligaments of cervical spine Dorsalgia Upper and mid back pain Sprain of ligaments of thoracic spine Muscle spasm of back Sprain of other parts of lumbar spine and pelvis Acute midline low back pain without sciatica Right wrist pain Unspecified sprain of right wrist Hip pain Contusion of left thigh Left knee pain, unspecified chronicity Other muscle spasm Whiplash injury syndrome

Treatments rendered

Medication: Pain medication Muscle relaxants Anti-inflammatories

Therapy: Physical therapy from 07/26/YYYY to 09/28/YYYY at

Therahand Physical TherapyCondition of the patient as per the last available record

As on 11/14/YYYY, she reports left posterior knee pain, which was aching. She also reports joint tenderness, numbness and tingling in the legs. MRI of the left knee reviewed. She had discussion regarding treatment options including physical therapy and injection. She will be continued to monitor. She was encouraged to do exercise. She might take Naprosyn as needed for pain.

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Patient History

Past Medical History: Migraines, early signs of menopause.

Surgical History: Non-contributory

Family History: Family history of alcoholism among mother, father, sister and brother. Mother had diabetes.

Social History: Never smoker, alcohol 6 drinks per week, no drug use.

Allergy: No known allergies

Detailed Summary

DATE FACILITY/ PROVIDER

MEDICAL EVENTS PDF REF

Summary of prior injury medical records

08/20/YYYY-10/10/YYYY

Hospital/Provider Multiple office visits:

08/20/2015: Diagnosed with tension headache, treated with Naprosyn 500 mg and Cyclobenzaprine 5 mg.

08/25/2015: Presents for preventive exam and irregular menses. Gynecological examination of cervical cancer screening performed.

09/15/2015: Patient underwent mammogram, which revealed there is no mammographic evidence of malignancy. Annual screening mammogram advised at 12 month interval.

10/30/2015: She received Tdap vaccine, tolerated injection well.

10/10/2016: She was diagnosed with stress bladder incontinence and treated with conservative measures including weight loss, dietary restrictions, avoiding coffee, soda caffeine.

*Comments: The above visits are not related to subjective injury hence not elaborated.

BSN 116, 142-153

Summary of post injury medical recordsDate of injury: 07/05/YYYY

07/05/YYYY Hospital/Provider Accident scene investigation report:

Date of collision: 07/05/YYYYStation: Brighton Station 51

Location type: IntersectionPrefix: S-SouthStreet or highway: MainStreet type: ST-Street

BSN 1-5

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City: City of BrightonState: CO, 80601Cross street: E Bridge St.

Incident type: 322 – Motor vehicle accident with injuriesAid given or received: None

Date and times:Alarm: 07/05/YYYY 09:50 hoursArrival: 07/05/YYYY 09:52 hoursLast unit cleared: 07/05/YYYY 10:37 hoursShift or platoon/district: B/250124

Primary action taken: 34 – Transport personProperty use: 963 – Street or road in commercial area.

Remarks:84oFWind: At 5 mphHumidity: 19%CR17-3370

E51, AMB52, BC51 dispatched to an injury accident at E Bridge St/S. Main St. on 07/05/YYYY at 09:50:01. All units en route from quarters, dry roads, warm temperatures, and no response issues. On arrival, I reported a motorcycle involved, rider walking attended by BPF. I established command, checking injuries. I found the female rider on her cell phone pointing to her knee and left leg. I saw road rash on her hand and she said she did not hit her head. E51 arrived and I referred her to FF Miller for assessment. I then checked the driver of the sedan and she had no complaints of injury. I directed AMB52 into the scene and PVAS medics assumed patient care. AMB52 TX NE x 1 to PVMC. I turned the scene over to BPD, all units available.

Apparatus/resource:ID: AMB52Type: 76-ALS unitDispatch: 07/05/YYYY 09:50 hoursArrival: 07/05/YYYY 09:56 hoursClear: 07/05/YYYY 10:37 hours

ID: BC51Type: 92-Chief officer carDispatch: 07/05/YYYY 09:50 hoursArrival: 07/05/YYYY 09:52 hoursClear: 07/05/YYYY 10:08 hours

ID: E51Type: 11-Engine

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Dispatch: 07/05/YYYY 09: 50 hoursArrival: 07/05/YYYY 09:53 hoursClear: 07/05/YYYY 10:08 hours

07/05/YYYY Hospital/Provider ER record:

ED arrival information:Arrival date/time: 07/05/YYYY 10:26 hoursAcuity: UrgentMeans of arrival: AmbulanceService: Emergency MedicineAdmission type: EmergencyAdmit date/time: 07/05/YYYY 10:27 amPoint of origin: Non Health Care Facility Point of OriginPrimary service: Emergency MedicineService area: Sci HealthUnit: Platte Valley (Pvb) Emergency Services

ED provider notes @ 10:38 hours:

Chief complaint: Patient presents with Motor vehicle crash Wrist pain Knee pain

History of present illness: Patient is a 46 year female who presents to the ED status post Motor Vehicle Accident (MVA) where she was not helmeted and her motorcycle was struck by a car while the patient was doing 20 mph, patient complains of right wrist, left knee pain and headache (HA), no Loss of Consciousness (LOC), happened at 1000 today.

Review of systems:Constitutional: Negative for fever and chills.Head, Ear, Nose, and Throat (HENT): Negative for ear discharge and ear pain.Eyes: Negative for photophobia and pain.Respiratory: Negative for cough and wheezing.Cardiovascular: Negative for chest pain and palpitations.Gastrointestinal: Negative for vomiting and abdominal pain.Genitourinary: Negative for dysuria and urgency.Musculoskeletal: Positive for joint pain. Negative for myalgias and back pain.Skin: Negative for itching and rash.Neurological: Positive for headaches. Negative for dizziness and tingling.Psychiatric/behavioral: Negative for depression and suicidal ideas.All other systems reviewed and are negative.

ED vital signs @ 10:32 hours:Blood pressure: 130/76 mmHgPulse: 67 beats/minute

BSN 6-14, 17-18

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Respiratory rate: 18 breaths/minuteTemperature: 97.9oFSpO2: 97%O2 delivery: RA-Room Air

Physical examination:Constitutional: She is oriented to person, place, and time and well-developed, well-nourished, and in no distress.Head: Normocephalic.Mouth/throat: Oropharynx is clear and moist.Eyes: Conjunctivae and Extraocular Movements (EOM) are normal. Pupils are equal, round, and reactive to light.Neck: Normal range of motion. Neck supple. No spinous process tenderness and no muscular tenderness present. No rigidity. Normal range of motion present.Cardiovascular: Normal rate, regular rhythm and normal heart sounds. No murmur heard.Pulmonary/chest: Effort normal and breath sounds normal. No respiratory distress.Abdominal: Soft. Bowel sounds are normal. She exhibits no distension.Musculoskeletal: Normal range of motion. She exhibits no tenderness.Arms: Mild swelling, full Range of Motion (ROM), no abrasion or lacerationLegs: Ecchymosis and Tender to Palpation (TTP), full Range of Motion (ROM) of the knee, no ligamentous laxity, no abrasion.Neurological: She is alert and oriented to person, place, and time.Skin: Skin is warm and dry. She is not diaphoretic.Psychiatric: Affect and judgment normal.Nursing note and vitals reviewed.

Radiology: X-ray of left knee and right wrist, CT of head and cervical spine were reviewed.*Comments: Direct report of the radiological studies were detailed in individual rows below for reference.

ED course & medical decision making: Pertinent labs & imaging studies reviewed. Patient present to the ED status post MVA with headache, knee pain and wrist pain, all imaging negative, she is feeling better and ready to go home. No neck pain, full ROM. She will Return to ED (RTED) if her symptoms change or worsen. All questions answered.

Final impression: Motorcycle accident, initial encounter Contusion of left thigh, initial encounter Wrist sprain, right, initial encounter Acute post-traumatic headache, not intractable

Final diagnosis: Unspecified sprain of right wrist, initial encounter

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Contusion of left thigh, initial encounter Acute post-traumatic headache, not intractable

Discharge information:ED disposition: DischargedDischarge date/time: 07/05/YYYY 12:40 hoursDischarge disposition: Home or self-careDischarge destination: Home

Prescribed medications: Hydrocodone-Acetaminophen, 5-325 mg take 1 tablet by mouth

every six hours, as needed for pain for up to 5 days. Naproxen sodium (Anaprox) 550 mg tablet take 550 mg by mouth

two times a day after meals for 10 days.07/05/YYYY Hospital/Provider CT of the cervical spine without contrast:

History: Motorcycle accident. Back pain. Head pain.

Findings: Axial images with coronal and sagittal reformatted views were

obtained. Degenerative disc disease with disc space narrowing and

spondylosis is present at C5-C6 and C6-C7. No fractures or subluxations are otherwise seen.

Impression: Degenerative disc disease in the lower cervical spine. No acute fractures or subluxations are noted.

BSN 14-15

07/05/YYYY Hospital/Provider CT of the head without contrast:

History: Headache after motorcycle accident.

Findings: Axial images with coronal reformatted views. The ventricles are midline. There is no hydrocephalus. No acute

ischemic or hemorrhagic process identified. No space-occupying masses.

Orbits and paranasal sinuses appear normal. Mastoid air cells normal.

No skull fractures.

Impression: Normal study.

BSN 15-16

07/05/YYYY Hospital/Provider X-ray of the right wrist 3 views:

Clinical history: Pain. Crash into road.

Findings: There is no fracture, subluxation, or dislocation. The joint spaces are within normal limits.

BSN 16

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Impression: No fracture, subluxation, or dislocation.07/05/YYYY Hospital/Provider X-ray of the left knee 3 views:

Clinical history: Pain bike crash

Findings: There is no fracture, subluxation, or dislocation. The joint spaces are within normal limits.

Impression: No fracture, subluxation, or dislocation.

BSN 16-17

07/11/YYYY Hospital/Provider Office visit:

Patient presents for MVA.

History of present illness: MVA: Onset: 6 days ago. The pain is aching. Context: There is an injury. Associated symptoms include bruising, joint tenderness and limping. Pertinent negatives include tingling in the arms and tingling in the legs. Additional information: Patient was involved in MVA while on motorcycle 6 days ago. Went to Platte Valley ER. Patient states X-rays leg and right hand and CT head and neck normal. Using walker to get around due to leg pain.

Review of systems:Musculoskeletal: Positive for joint tenderness, limpingHematological/lymphatic: Positive for bruising.

Physical examination:Musculoskeletal: Some bruising left leg. Full Range of Motion (FROM) of joints. Tender bilateral paraspinous muscles in back.Neurological: 2+ Deep Tendon Reflexes (DTR), 5/5 Lower Extremity (LE) strength. Negative Straight Leg Raise (SLR)

Assessment/plan: Assessment: Whiplash injury syndrome, initial encounter & MVA

(Motor Vehicle Accident), initial encounter.Plan: Patient was in MVA on motorcycle about 6 days. Was in ER and had negative X-rays of right wrist, left leg. Also has negative CT of neck and head. Patient has muscle relaxer, Naprosyn and Vicodin from ER. Neurovascularly Intact (NVI) today. Continue to rest ice. May take 4-6 weeks with musculoskeletal strains. Follow-up in 2 weeks or sooner if persists.

Assessment: Screening for breast cancer.

Plan: Further diagnostic evaluations ordered today includes mammogram digital screening be performed.

Medication prescription: Cyclobenzaprine 5 mg take 1 tablet by oral route 2 times every day

BSN 36-38, 139-141

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Naprosyn 500 mg take 1 tablet by oral route 2 times every day with food

07/19/YYYY Hospital/Provider Follow-up visit:

Patient presents for follow up of MVA.

History of present illness: MVA: Onset: 2 weeks ago. The pain is aching. Context: Motor vehicle accident. The pain is aggravated by bending. The pain is relieved by pain/treatment medications and rest. Associated symptoms include decreased mobility and nocturnal awakening. Pertinent negatives include bruising, joint instability, limping, numbness, tingling in the arms and tingling in the legs. Additional information: Patient was in MVA on motorcycle about 2 weeks ago. Was clipped and spilled bike. Denies numbness tingling legs or arms. No radiating pains. Currently pain mid back. Taking Naprosyn.

Review of systems:Constitutional: Positive for nocturnal awakening.Musculoskeletal: Positive for decreased mobility.

Physical examination:Neurological: Negative Straight Leg Raise (SLR) bilaterally. 5/5 lower extremity strength. Tender lower thoracic, lumbar area to palpation. No redness or swelling.

Assessment/plan:Assessment: Acute midline low back pain without sciatica & MVA (motor vehicle accident), subsequent encounter.Plan: MVA on motorcycle about 2 weeks ago. Still having some back pains. Using walker to ambulate. Pain medication little relief. Neurovascularly Intact (NVI) today. Will get MRI of lumbar spine. Will begin referral to physical therapy if MRI stable.Plan orders: Further diagnostic evaluations ordered today includes MRI lumbar spine without contrast to be performed.Referrals: Physical therapy. Evaluate and treat for physical therapy.

Medication prescription: Cyclobenzaprine 5 mg take 1 tablet by oral route 2 times every day Naprosyn 500 mg take 1 tablet by oral route 2 times every day with

food

BSN 33-35, 136-138

07/20/YYYY Hospital/Provider MRI of lumbar spine without contrast:

History: Motorcycle accident. Low back pain.

Findings: Vertebral body height is maintained at all levels. There is no

evidence of compression deformity. Alignment is normal. There is no evidence of subluxation. Bone marrow signal is normal.

BSN 46-47, 119-120

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There is no evidence of bone lesion. Conus medullaris terminates at L1.

Axial images demonstrate the following: L2-3: No disc herniation, spinal stenosis, or neural foraminal

stenosis. L3-4: Left foraminal disc protrusion. Moderate left foraminal

narrowing. No spinal canal narrowing. No right foraminal narrowing.

L4-5: Mild posterior disc bulging and facet arthrosis. Possible small right foraminal annular fissure. No spinal canal or neural foraminal stenosis.

L5-S1: Tiny left paracentral disc protrusion. Mild facet arthrosis. No spinal canal or neural foraminal stenosis.

No epidural abnormality.

Impression: Degenerative changes at L3-4, L4-5, and L5-S1 as described.07/26/YYYY Hospital/Provider Follow-up visit:

Patient presents for follow up of MVA.

History of present illness: Follow-up of MVA: Onset: 3 weeks ago. The pain is aching. Context: Motor vehicle accident. The pain is aggravated by climbing stairs and lifting. Associated symptoms include decreased mobility, joint tenderness, nocturnal pain and weakness. Pertinent negatives include bruising, crepitus, limping, numbness, swelling, tingling in the arms and tingling in the legs. Additional information: Patient here to fill out paperwork for work restrictions. Has slowly been improving. No longer using walker. Still having pains and unable to work full time without restriction as of yet.

Review of systems:Constitutional: Positive for nocturnal pain.Musculoskeletal: Positive for decreased mobility, joint tenderness, weakness.

Physical examination:Musculoskeletal: Still having tenderness to thoracic and lumbar paraspinous muscles to palpation. NVI.

Assessment/plan:Assessment: Acute midline low back pain without sciatica & MVA (Motor Vehicle Accident), subsequent encounter.Plan: Pain improving but persists. Patient here for work restriction paperwork today. Completed with patient. Patient states X-rays and CT of head and neck Within Normal Limits (WNL) from ER, no records yet. Continue medication as needed. Recheck in 2 weeks.

Medication prescription: Cyclobenzaprine 5 mg take 1 tablet by oral route 2 times every day

BSN 31-32, 134-135

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Naprosyn 500 mg take 1 tablet by oral route 2 times every day with food

07/26/YYYY Hospital/Provider Medical questionnaire:

Do you take Coumadin (blood thinner): NoDo you take any other anticoagulation medicine? NoIn the past, have you received any blocks or injections for this problem? No

What is your major complaint? Back pain, some neck pain.When did this condition begin? 07/05/YYYYHow did this condition begin? Motorcycle accident.Have you ever had this problem or a similar problem before? NoHave you lost work days? Yes.If yes, how many days? 17Have you returned to your same job? NoIf not, why? Requires too much movement and unable to do that.

Has this problem been getting better, worse, or staying the same? WorseWhat makes the pain worse? MovementWhat makes the pain better? Sitting down, pain medications.Does the pain travel from its site to anywhere else in your body? YesWhat kind of pain do you have? Aching, can be sharp at times.Rate the pain 1-10: 4/10What time of day does the pain occur? All dayDoes the pain wake you up? NoIs the pain constant? YesHave you received any treatment for this condition? YesIf yes, where, when and what were the results? MRI, seen Dr. twice – prescribed pain medications.Please list all medications: Cyclobenzaprine 5 mg, Naprosyn 500 mg, and anti-inflammatory 500 mg.Please list any surgeries or hospitalizations: None.

Present conditions: Neck pain or stiffness Upper or mid back pain Low back pain or stiffness Some hip pain Fatigue

Others: Complaints of aching on the neck, upper mid back, stabbing over the low back.

BSN 48-51

07/26/YYYY Hospital/Provider Automobile accident questionnaire:

Date of accident: 07/05/YYYYHow much damage to your vehicle: Don’t know yet

BSN 52-53

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Other vehicle: Front bumperYou were heading: East on Bridge streetOther vehicle was headed: West on Bridge streetYou were struck from: FrontWhich direction was your head facing at the time of impact: ForwardDid your body hit any part of the car during the impact? YesYou were: The driverWere you wearing seat belt? NoWere police notified? YesAmbulance: YesWere you knocked unconscious? NoWhere were you taken after the accident? Platte Valley Medical CenterWhat treatment was given? X-rays, MRI on neck and head.Was X-ray taken? YesHead injury? NoFractures? NoWas pain: ImmediateWas there alcohol or drugs involved? NoWas any other doctor consulted after your accident? YesIf so, what was the doctor's name? Dr. Darren RothWhat do you do for a living? Work with teensHas your job been affected and how? Yes, have not been able to return to work.Please list any other activities affected: Daily movement, daily living activities.Please list any activities that worsen your pain: MovingPlease list what relieves your pain: Pain medications, little movement.

07/26/YYYY Hospital/Provider Physical therapy initial evaluation:

Injury/onset/change of status date: 07/05/YYYY new injury, motorcycle accident

History of present condition/mechanism of injury: Status post MVA on 07/05/YYYY. ER visit: Yes, MRI and CT scan.

Primary concern/chief complaint: Primary pain area and type of pain: Neck pain: 4/10 (intermittent, achy with movement), mid back: 5-7/10 (constant, stabbing, sharp, worse with 30 minutes sitting, walking, bending), low back: 8-10/10 (constant, sharp, stabbing, worse with any movement), sleeping disturbance due to severe pain.

Current functional limitations:Self-care: SleepChanging & maintaining body position: Maintaining a body position: Remaining seated, remaining standing.Mobility: Walking & moving around: Walking

Patient goals: Return to Activities of Daily Living (ADLs) with tolerable pain.

BSN 54-60

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Objective:Outcome measurement tools:Pain: Wong-Baker FACES Pain Rating Scale: 5

Range of motion: Active Range of Motion (AROM):Cervical AROM PatientsForward bending 80%Backward bending 90%Right rotation 80%Left rotation 90%Right side bending 80%Left side bending 90%

Lumbar AROM PatientsForward bending 30%Backward bending 50%Right rotation 50%Left rotation 50%Right side bending 30%Left side bending 20%

Neuro-vascular:Lower reflexes: All normal

Special test Right LeftKnee jerk (L4) 2 + Normal 2 + NormalAnkle jerk (S1) 2 + Normal 2 + NormalLasegue’s SLR Negative Negative

Palpation:Bilateral cervical paraspinals: Tender with increased tissue tensionCervical spinous processes left: Localized point of tendernessCervical spinous processes: Painful to deep palpationBilateral levator scapula, bilateral thoracic paraspinals: Tender with increased tissue tension, involuntary muscle holding (spasms)Bilateral quadratus lumborum: Painful to light palpation, involuntary muscle holding (spasms).

Diagnosis: Sprain of ligaments of cervical spine, subsequent encounter Sprain of ligaments of thoracic spine, subsequent encounter Sprain of other parts of lumbar spine and pelvis, subsequent

encounter Motorcycle rider (driver) (passenger) injured in unspecified traffic

accident, subsequent encounter

Treatment diagnosis:

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Cervicalgia Dorsalgia, unspecified Low back pain Other muscle spasm Muscle spasm of back

Assessment/diagnosis: Patient’s signs and symptoms are consistent with medical diagnosis.Primary functional limitation: Self-careCurrent status: G8987: CL, At least 60% but < 80% impaired, limited or restricted.Projected goal status: G8988: CH, 0% impaired, limited or restricted.Severity % rationale: Severity modifier selections based on the Wong-Baker FACES Pain Rating Scale scoring, objective findings and co-morbidity assessment.Patient education: Will initiate Home Exercise Program (HEP)Rehab potential: GoodContraindications to therapy: None

Patient problems: Limitations with self-care Joint dysfunctions Multiple muscle spasms and tenderness

Plan:Frequency: 2 times a weekDuration: 8 weeksPlan: Begin plan as outlined

Treatment to be provided:Procedures: Therapeutic exercises (ROM, strength, endurance, stability), neuromuscular rehabilitation (sequencing, coordination, Redcord neurac (neuromuscular-activation)), manual therapy (soft tissue mobilization, joint mobilization, spinal mobilization, myofascial release, muscle energy techniques, manual resistive exercise, dry needling/intramuscular manual therapy, Graston or ASTYM techniques)

Modalities: To improve (pain relief, decrease inflammation, increase blood flow, improve tissue healing), electrical stimulation (pre-modulated).

07/28/YYYY-09/26/YYYY

Hospital/Provider Interim physical therapy records:

Treatment diagnosis: Cervicalgia Dorsalgia, unspecified Low back pain Other muscle spasm Muscle spasm of back

Therapies given: Therapeutic exercises (ROM, strength, endurance,

BSN 61-104

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stability), neuromuscular rehabilitation (sequencing, coordination, Redcord neurac (neuromuscular-activation)), manual therapy (soft tissue mobilization, joint mobilization, spinal mobilization, myofascial release, muscle energy techniques, manual resistive exercise, dry needling/intramuscular manual therapy, Graston or ASTYM techniques).

She received physical therapy on following dates: 07/28/YYYY, 07/31/YYYY, 08/03/YYYY, 08/07/YYYY, 08/09/YYYY, 08/14/YYYY, 08/16/YYYY, 08/21/YYYY, 08/23/YYYY, 08/28/YYYY, 08/30/YYYY, 09/05/YYYY, 09/07/YYYY, 09/11/YYYY, 09/14/YYYY, 09/19/YYYY, 09/21/YYYY, 09/26/YYYY.


History of present illness: Follow-up of MVA: The problem is improving. The pain is aching. Context: Motor vehicle accident. The pain is aggravated by lifting, movement and standing. Associated symptoms include decreased mobility. Pertinent negatives include limping, swelling and weakness. Additional information: Patient with low back pain since MVA. Patient states improving but still having back pains with walking or standing long term. Patient does do a lot of standing and walking at work.

Review of systems:Musculoskeletal: Positive for decreased mobility

Physical examination: Normal

Assessment/plan:Assessment: Acute midline low back pain without sciatica & MVA (Motor Vehicle Accident), subsequent encounter.Plan: Low back pain since MVA. Patient in physical therapy, states improving but still having issues with long period or standing or walking. Patient interested in going to water therapy. She doesn’t feel she is able to return to her job working with kids. Will follow-up to repeat paperwork for Family and Medical Leave Act (FMLA).


food

BSN 132-133


Patient presents for follow up of back pain.

History of present illness: Follow-up of back pain: Location of pain is middle back and lower back. Context: Motor vehicle accident. Additional information: Patient here for mid and lower back pain and for disability paperwork. She is improving but slowly. Doing physical therapy and water therapy.

BSN 29-30, 130-131

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Physical examination: Normal

Assessment/plan:Assessment: Acute midline low back pain without sciatica & MVA (Motor Vehicle Accident), subsequent encounter.Plan: Here to fill out paperwork for FMLA. Patient has extended her FMLA to maximum time as she improved from an MVA and low back pain. Patient still having tenderness, improving with physical therapy and water therapy. Paperwork completed. Follow-up with any issues after returning to work in September.


food.09/05/YYYY Hospital/Provider Follow-up visit:

History of present illness: Follow-up of back pain: Additional information: Patient set to go back to work. Low back pain overall improving. Has been on disability after MVA. In water, physical therapy.

Review of systems: All systems are negatives.

Physical examination:Neurological: No pain to palpation, 2+ DTR, negative SLR, 5/5 lower extremity strength.

Assessment/plan:Assessment: Acute midline low back pain without sciatica & MVA (Motor Vehicle Accident), subsequent encounter.Plan: Patient here for release to return to work. No pain on exam today, NVI. Doing much better overall. Note given to return to work today. Follow-up with any recurring pains.

Assessment: Encounter for screening for other disorder.

Plan orders: Orders not associated to today’s assessments. The patient had the lab tests completed today, Hemoglobin 13.7 mg/dl.

Medication prescription: Cyclobenzaprine 5 mg take 1 tablet by oral route 2 times every day. Naprosyn 500 mg take 1 tablet by oral route 2 times every day with

food.

BSN 26-28, 127-129

09/28/YYYY Hospital/Provider Physical therapy discharge summary:

Date of discharge summary: 09/28/YYYY

Injury/onset/change of status date: 07/05/YYYY

BSN 105-108

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Visit no: 13

Subjective:History of present condition/mechanism of injury: Status post MVA on 07/05/YYYY. ER visit: Yes, MRI and CT scan

Current complaints/gains: Primary pain area and type of pain: Neck pain: 1/10 (intermittent, achy with movement), mid back: 1/10 (intermittent, achy, worse with 30mins sitting, walking, bending), low back: 1/10 (intermittent, achy, stabbing, worse with any movement).

Current functional limitations:Self-care: SleepChanging & maintaining body position: Maintaining a body position: Remaining seated, remaining standing.Mobility: Walking & moving around: Walking.

Functional deficits/gains: “I feel some achiness in my back and hip”

Objective:Outcome measurement tools:Pain: Wong-Baker FACES Pain Rating Scale: 1; previous 3

Range of motion: Active Range of Motion (AROM):Within Normal Limit (WNL)Within Functional Limit (WFL)

Cervical AROM Patients PatientsForward bending WNL WNLBackward bending WNL WNLRight rotation WNL WNLLeft rotation WNL WNLRight side bending WFL WNLLeft side bending WNL WNL

Lumbar AROM Patients PatientsForward bending WNL 60%Backward bending 75% 75%Right rotation WFL 75%Left rotation WNL 75%Right side bending WNL 75%Left side bending WNL 75%

Neuro-vascular:Lower reflexes: All normal

Special test Right LeftKnee jerk (L4) 2 + Normal 2 + Normal

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Ankle jerk (S1) 2 + Normal 2 + NormalLasegue’s SLR Negative Negative

Palpation:Left gluteal area and piriformis left: TenderRight quadratus lumborum: NormalLeft quadratus lumborum: Painful to deep palpation.

Diagnosis: Sprain of ligaments of cervical spine, subsequent encounter Sprain of ligaments of thoracic spine, subsequent encounter Sprain of other parts of lumbar spine and pelvis, subsequent

encounter Motorcycle rider (driver) (passenger) injured in unspecified traffic

accident, subsequent encounter

Treatment diagnosis: Cervicalgia Dorsalgia, unspecified Low back pain Other muscle spasm Muscle spasm of back

Assessment:Assessment/diagnosis: Tolerance/response to therapeutic exercises: Good. Tolerance/response to all other treatments: Good.Primary functional limitation: Self-careDischarge status: G8989: CI, At least 1% but < 20% impaired, limited or restricted.Projected goal status: G8988: CH, 0% impaired, limited or restricted.Severity % rationale: Severity modifier selections based on the Wong-Baker FACES Pain Rating Scale scoring, objective findings and co-morbidity assessment.Rehab potential: GoodPatient problems:

Limitations with self-care Joint dysfunctions Multiple muscle spasms and tenderness

Plan:Reason: All goals met.Discharge: Discharge to HEP


Patient presents for knee pain.

History of present illness: Knee pain: Onset: 2 months ago. The problem is fluctuating. Location: Left knee. There is no radiation. The pain is aching.

BSN 124-126

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Context: There is no injury. Associated symptoms include decreased mobility, joint tenderness and limping. Pertinent negatives include bruising, crepitus, swelling and weakness. Additional information: Patient with posterior left knee pain for 2 months. States worsening. Worse with ambulation and full flexion. Denies known injury. Was going to physical therapy for back.

Review of systems:Musculoskeletal: Positive for decreased mobility, joint tenderness, limping.

Physical examination:Musculoskeletal: Full Range of Motion (FROM) of knee. Negative Lachman’s, negative McMurry’s. Tender posterior knee.

Assessment/planAssessment: Left knee pain, unspecified chronicityPlan: Mostly posterior knee pain. No Bakers cyst palpated but does have pain to palpation. Otherwise knee appears stable. Discussed options. Patient would like to proceed directly to MRI which was ordered today. May take Naprosyn for pain. Follow-up depending on results.Plan orders: Further diagnostic evaluations ordered today includes MRI knee without contrast - left knee to be performed.


food11/09/YYYY Hospital/Provider MRI of the left knee without contrast:

History: Posterior knee pain for 3 weeks.

Findings: Meniscus: Medical and lateral meniscus appear intact. Cruciate ligaments: Normal Collateral ligaments: Normal Tendons: Unremarkable Cartilage: Cartilage within the medial, lateral, and patellofemoral

compartment appear normal. Bones: The osseous structures appear normal without fracture or

bone lesion. Soft tissues: There is some nonspecific edema overlying the

patellar tendon particularly along its distal margin. There is a very tiny Baker’s cyst. Physiologic volume of joint fluid is seen. Regional muscles and neurovascular structures appear normal.

Impression: Tiny Baker’s cyst. Nonspecific edema overlying the patellar tendon. The examination is otherwise normal. Specifically the meniscus,

BSN 117-118

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cruciate and collateral ligaments appear intact.11/14/YYYY Hospital/Provider Follow-up visit:

History of present illness: Follow-up of knee pain: Location: Left knee. The pain is aching. Associated symptoms include joint tenderness, numbness and tingling in the legs. Pertinent negatives include bruising, crepitus, limping, locking, popping, spasms, swelling, tingling in the arms and weakness. Additional information: Posterior left knee pain follow-up. Here to review MRI. Patient states knee pain started after physical therapy after MVA. Does have Low Back Pain (LBP) since MVA also. Did therapy for back. MRI essentially normal.

Review of systems:Neurological: Positive for numbness and tingling in the legs.Musculoskeletal: Positive for joint tenderness.

Physical examination:Musculoskeletal: FROM of knee. No redness, swelling. No pain to palpation. No instability. Negative Homan’s.

Assessment/plan:Assessment: Left knee pain, unspecified chronicity.Plan: Here to review MRI. Posterior knee pain started when doing physical therapy for back. No injury. Normal knee exam without pain. Reviewed MRI. No clear etiology for pain. Baker’s cyst likely not cause. Discussed options including physical therapy, injection. Patient will continue to monitor. Encouraged exercise. May take Naprosyn as needed.

Plan orders: Orders not associated to today’s assessments. Today’s instructions/counseling includes lifestyle education regarding diet. Prescribed activity/exercise education.

Medication prescription: Cyclobenzaprine 5 mg take 1 tablet by oral route every day. Naprosyn 500 mg take 1 tablet by oral route 2 times every day with

food.

BSN 121-123

Other records:

Authorization, consent, others, medical bills, labs, patient’s information.

Pdf Ref: BSN 19-25, 39-45, 109-115.

*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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