New Ime Medical Report

[lu12]

Northeastern Chiropractic Center, Inc. December 17, 2007

Patient: DOB:

Chief Complain

A 41 years old Hispanic male presents to chiropractic office on 04/03/2007 with neck pain, bilateral shoulder pain and low back pain with Radioculopathy to both legs.

The onset of symptoms started suddenly after having an accident while attending the military in 1988. Mr.--------- reported that he initially hurt his lumbar region and his right knee then his cervical spine. Mr. --------- reported some improvement with Flexeril and Neurontin medications but also reported that walking, prolonged sitting, driving and activities of daily living makes condition worse.

Patient described the quality of pain as achy/stabbing on lumbar spine, numbness/tingling on left foot (lateral aspect) and dull/achy on cervical region. He reported that pain radiates to hands and feet bilaterally. Patient described the pain as constant. Mr. --------denied any bladder or bowel dysfunction at the time of initial examination but reported pain during sexual relations.

There is a history of multiple motor vehicle accidents (MVA) on 1997, 2000 and most recent on 2005 (all of them were rear impact) according to Mr. --------Medical care provided by the Veterans Affair and other private practitioners including physical medicine specialist, neurologist, orthopedic surgeon and chiropractic care by Dr. ---------- on 2003 had been provided since the onset of symptoms with minimal improvement according to patient.

Vital Signs

BP: 130/90 L Pulse: 80 ppm Resp: 16 bpm Temp: NP Weight: 234 Ibs Ht: 5'9"

Neurological Examination

Alert x 3

Cranial nerves were intact.

Cerebellar test was unremarkable.

Motor: 5/5 C5-T1 and LI-SI

DTK's: +2 bilateral on upper and lower extremities.

Sensation: Decreased sensation on right leg L4 and L5 dermatome

Decreased Active ROM

Cervical region: j extension 35°, J, left lateral flexion 35°, right lateral flexion 40°,

J, rotation 65° Bilateral

Thoracic region: j, extension.

Lumbar region: I flexion 45°, j extension 15°, J, bilateral lateral flexion 20°, J, bilateral rotation 20°

Orthopedic Examination

Pain elicited upon Cervical compression, right shoulder depression test, positive minor sign, positive Kemp's test, SLR @ 45°, Braggard's test, Ely's test, Yeoman's test, Apley's compression right knee.

Postural Evaluation

Mr. ---------- posture showed an anterior head carriage, rounded shoulders,

hypolordosis of lumbar spine and a high right pelvis.

Spinal Evaluation

Segmental fixations were found between C3/C4, C7/T1, T4/T5, L4/L5 and L5/S1

vertebral segments.

Soft Tissue Evaluation

Spasms were found upon palpation of left lumbar spinal muscles, right trapezium muscle

bilateral rhomboid muscles.

Radiological and Advance Studies (*) Lumbar MRI done on 06/19/2007 revealed:

1. Moderate central disc protrusion at L5/S1.

2. Right posterolateral disc protrusion at L4/L5.

3. Lumbar Spine disc desiccation at L3/L4, L4/L5 and L5/S1 discs.

Cervical MRI done on 04/30/2007 revealed:

1. Small central disc protrusion at C3/C4.

2. Small central disc protrusion at C2/C3 causing mild impression upon the

anterior thecal sac.

3. Moderate to severe bilateral neural foramina narrowing at C4/C5 disc with

degenerative spondylosis.

4. Cervical disc desiccation of C5/C6 disc.

Whole Body Bone Scan done on 02/27/2007 revealed inflammatory changes at the acromioclavicular joints, right knee, right ankle and dental process of the maxilla.

Pelvis Radiograph done on 09/15/2006 revealed mild degenerative changes at sacroiliac joints.

Thoracic Radiograph done on 09/15/2006 revealed mild thoracic levoscoliosis.

Electrodiagnostic studies (NCV/EMG) revealed:

1. L5 and S1 right radiculopathy on 08/25/2005.

2. Mild bilateral median nerve entrapment across the carpal tunnel on 08/02/05.

3. Bilateral ulnar nerve entrapment below elbow on 10/01 /2003.

(*) See study impression.

Diagnosis:

Lumbar disc protrusion L4/L5 and L5/S1

Lumbar degenerative disc disease L3/L4

Cervical disc protrusion C3/C4 and C2/C3

Cervical neural foraminal stenosis and spondylosis C4/C5

Cervical degenerative disc disease C5/C6

Myofascial pain syndrome of cervical, thoracic and lumbar paraspinal muscles

Upper cross Syndrome

Tension Headaches

Scoliosis thoracic spine

Osteoarthritis right knee (post traumatic)

Prognosis:

Prognosis at this stage is poor to fair if patient follows recommendations and avoids

Trauma.

Treatment Provided:

Chiropractic care consisted of Flexion/Distraction therapy Cox Protocol, Chiropractic

Manipulative therapy (CMT) of cervical, thoracic, lumbar and sacroiliac regions.

Physical therapy consisted of Hot/Cold packs 15 minutes intervals as needed, interferential current (IFC) x IS minutes 1-150 Hz and soft tissue manipulation (ischemic compression/cross friction massage).

Recommendations:

In my professional opinion Mr.------- presents with a chronic condition cause

Initially by trauma while in service in the military followed by moderate to severe

Degenerative process of the spine as a result of disability and repetitive trauma from

MVA's. His spinal and extremities conditions although slightly improve after more than

25 chiropractic visits since 04/03/2007 may aggravate or worsen due to anatomical

changes such as degenerative process, disc herniations, postural changes, increase body

weight and also emotional disorders cause by pain, inability to performed normal

activities and inability to exercise properly due to physical disabilities.

It is necessary to continue chiropractic care with medical co-management to maintain Mr.

--------- functioning to the best of his functional capabilities.

Berta, Pete I think this is not good enough as supporting evidence for my cervical spine issue?

your advice will be truly appreciated.

lu12

Edited January 20, 2008 by lu12