Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915 September 10, 2007 Law offices of xxxxxxxxx Santa Monica, CA 90405 REGARDING: AGE: DATE OF INJURY: DATE OF INITIAL EXAMINATION: DATE OF FINAL EXAMINTION: SAMPLE PERSONAL INJURY MEDICAL REPORT Dear Attorney: Ms. xxxxxxxxx is an 18-year-old female who was evaluated in this office on June 25, 2007, for injuries she claimed to have sustained in a motor vehicle accident. This incident occurred on the above captioned date. The following represents the history, findings on initial examination, course of treatment, prognosis, and recommendations. HISTORY OF PRESENT ILLNESS: According to the patient, she was the passenger and had her seatbelt fastened when the vehicle in which she was riding in was involved in a rear-end collision. The patient states that they were traveling eastbound on the 60 Freeway when the car behind them was struck by another vehicle; the force of which caused that vehicle to strike the patient s vehicle from behind. The force of that impact pushed the patient's vehicle forward, causing it to strike the vehicle in front of it. Upon impact the patient's head and body were jolted forward and backward multiple times. She experienced immediate pain and sensation in her neck. The police were called to the scene. A report was filed. No medical attention was rendered at the scene. The patient reported that her pain increased overnight and that she had difficulty sleeping due to her accident-related injuries.
INITIAL COMPLAINTS: At the time of medical examination, the patient s chief complaints included pain in her neck, shoulders, and mid-back. The patient rated the pain in her neck at 9/10 on the pain scale and described the pain as a stretching/pulling with stiffness. The patient rated the pain in her midback at 7/10 on the pain scale. The pain increases when bending, stooping, squatting, pushing, pulling, kneeling, prolonged standing, sitting or walking, climbing, reaching, lifting or carrying over 10 lbs. The patient rated the pain in her shoulders at 7/10 on the pain scale. The pain increases upon pushing, pulling, reaching, lifting or carrying over 10 lbs. The pain radiates down her upper arms bilaterally. The patient is unable to sleep throughout the night; waking several times due to the pain in her neck and back. She has been unable to perform some of her job duties as a waitress due to pain and inability to lift more than 10 lbs. PAST MEDICAL HISTORY: The patient's past medical history was essentially unremarkable and non-contributory. She denied any history of serious illness, previous accidents or previous surgery. INITIAL PHYSICAL EXAMINATION: The patient is an 18-year old female who is well nourished, alert, responsive, and cooperative. She appeared to be in no acute distress. PHYSICAL EXAMINATION: GENERAL: VITAL SIGNS: SKIN: HEAD: EENT: The patient is a 18-year-old, right-handed female who is well nourished, alert, responsive, and cooperative. Stable. The skin was clear with no bruises, abrasions, or lacerations noted. The head was normocephalic with no external signs of injury. The pupils were equal, round, and reactive to light and accommodation. The tympanic membranes were intact. The nose and throat were clear.
CHEST: LUNGS: HEART: ABDOMEN: CERVICAL SPINE: The chest was symmetrical. Normal AP diameter and respiratory excursions were noted. Examination of the rib cage was within normal limits. The lungs were clear to percussion and auscultation. The heart had regular rate and rhythm without murmurs or gallops. Examination of the abdomen revealed the presence of tenderness on palpation of the umbilical region. No masses or lesions were noted on palpation. Inspection of the cervical spine revealed normal lordosis without evidence of antalgic positioning. Examination of the cervical spine revealed tenderness on palpation of the spinous processes and paraspinal musculature. No spasms were detected on palpation. No guarding was noted on examination. Foraminal Compression was negative. Distraction was negative. No motor or sensory deficit to either upper extremity was noted. Range of motion was as follows: ORTHOPEDIC EVALUATION: Cervical Spine: Examination of the cervical spine revealed tenderness and spasm on palpation of the paraspinal musculature. Foraminal Compression was negative. Distraction was negative. Range of motion was as follows: Flexion: Extension: Right lateral bending: Left lateral bending: Right rotation: Left rotation: 40 / 45 degrees, elicited mild pain 40 / 45 degrees, elicited mild pain 45 / 45 degrees, elicited mild pain 45 / 45 degrees, elicited mild pain 90 / 90 degrees 90 / 90 degrees Thoracic Spine: Examination of the thoracic spine revealed tenderness and spasm on palpation of the paraspinal musculature.
Lumbosacral Spine: Examination of the lumbosacral spine revealed tenderness and spasm on palpation of the paraspinal musculature. The straight leg raise test was positive. Range of motion was as follows: Flexion: Extension: Right lateral bending: Left lateral bending: Right rotation: Left rotation: 60 / 90 degrees, elicited pain 25 / 30 degrees 35 / 35 degrees 35 / 35 degrees 45 / 45 degrees 45 / 45 degrees Shoulders: Examination of the shoulders revealed mild to moderate tenderness on palpation of the right trapezius and right bicipital groove. Range of motion was as follows: Right Left Normal Flexion: 180 degrees 180 degrees 180 degrees Extension: 60 degrees 60 degrees 60 degrees Abduction: 180 degrees 180 degrees 180 degrees Adduction: 50 degrees 50 degrees 50 degrees External rotation: 90 degrees 90 degrees 90 degrees Internal rotation: 90 degrees 90 degrees 90 degrees Neurological: The patient was oriented to person, place and time. Her speech was normal. The patient ambulated with a non-antalgic gait. Romberg was well performed. Deep tendon reflexes were within normal limits. RADIOLOGICAL REPORTS: X-rays of the cervical spine were performed at Advanced Professional Imaging Medical Group. Please see attached reports. DIAGNOSES: 1) 847.0 CERVICAL SPINE SPRAIN AND STRAIN 2) 847.1 THORACIC SPINE SPRAIN AND STRAIN 3) 846.0 LUMBOSACRAL SPINE SPRAIN AND STRAIN 4) 923.0 RIGHT SHOULDER CONTUSION
COURSE OF TREATMENT: The patient initially presented in the office on June 25, 2007, for evaluation of injuries she claimed to have sustained in a motor vehicle accident. This incident occurred on June 17, 2007. Following a physical examination, the patient was prescribed a course of physical therapy including tens, heat packs, traction, and chiropractic manipulation. Physical therapy was recommended to be scheduled three times per week for a period of four weeks. The patient returned to the office on July 16, 2007, for re-evaluation. At that time, she had complaints of neck, back and shoulder pain. The pain in her neck was rated at 5/10 on the pain scale and is relieved by physical therapy and chiropractic manipulation. The pain in her back is rated at 5/10 on the pain scale and is relieved by physical therapy and chiropractic manipulation. The pain in her shoulders is rated at 5/10 on the pain scale and is relieved by physical therapy and chiropractic manipulation. A review of the X-ray results revealed a shifting of the cervical spine accompanied by muscle spasms. Examination of the cervical spine revealed tenderness and spasm on palpation of the paraspinal musculature. Examination of the thoracic spine revealed tenderness and spasm on palpation of the paraspinal musculature. Examination of the lumbosacral spine revealed tenderness and spasm on palpation of the paraspinal musculature. Examination of the shoulders revealed tenderness on palpation. Based on these findings, the patient was recommended to continue with the conservative treatment three times per week for a period of four weeks. The patient returned to the office on August 13, 2007, for re-evaluation. At that time, she had complaints of pain in her neck rated at 4/10 on the pain scale. The patient denied any pain in her back or shoulders. Examination of the cervical spine revealed tenderness on palpation of the paraspinal musculature with increased pain on movement. Examination of the thoracic spine revealed full range of motion with no tenderness noted on palpation. Examination of the lumbosacral spine revealed no tenderness on palpation, with full range of motion. Based on these findings, the patient was recommended to continue with the conservative treatment twice per week for a period of four weeks. The patient was seen for final evaluation on September 10, 2007. At that time, she had complaints of mild pain in the right side of her neck rated at 2/10 on the pain scale. Examination of the cervical spine revealed full range of motion with no tenderness noted on palpation. Examination of the thoracic spine revealed full range of motion with no tenderness or spasm noted on palpation. Examination of the lumbosacral spine revealed full range of motion with no tenderness or spasm noted on palpation. Examination of the shoulders revealed full range of motion with no tenderness or spasm noted on palpation bilaterally. The patient was discharged from our care at this time.
DISCUSSION AND RECOMMENDATIONS: The patient sustained injury to her neck, back, and shoulders in a motor vehicle accident, which occurred on June 17, 2007. Since the patient s initial presentation on June 25, 2007, she has been treating at this office and has participated in a course of chiropractic manipulation and physiotherapy to facilitate a prompt and successful recovery. At the time of final evaluation, the patient had minor residual symptomatology. FUTURE MEDICAL CARE: Provisions for the future medical care should be made to include re-examinations and short courses of physical therapy, should the patient s symptoms become exacerbated. PROGNOSIS: The prognosis in this case is guarded. In view of the nature of the injury this patient sustained, it is quite probable that she will continue to have exacerbations and remissions at intervals in the future. These exacerbations can be brought on by stress, strenuous physical exertion, and, sometimes, by ordinary daily activities. Please do not hesitate to contact me should you require any further information concerning this patient. DISCLOSURE/AFFIDAVIT OF COMPLIANCE: This report is for medical/legal assessment and is not to be construed as a complete physical examination for general health purposes. Only those symptoms which I believed to have been involved in the injury, or might relate to the injury, have been assessed. According to labor code 4628, I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I have received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe is to be true. I have not violated Labor Code Section 139.3, and the contents of the report and bill are true and correct to the best of my knowledge. This statement is made under penalty of perjury. Dated this day of 2007 at Los Angeles County, California. Sincerely, Gilbert R. Varela, M.D. GRV:cv