JANE DOE - C&C Transcription, Inc.

JANE DOE

–

09/22/2005

Headaches are rated at eight. They happen about every day. It occurs occipitally and frontally.

Cervical spine pain rating eight. Thoracic spine seven. Lumbosacral spine five.

This Hispanic female born 01/23/4567 was sitting as a right front passenger in an unmoving vehicle when the vehicle was impacted from the rear. She was wearing a seatbelt. Air bags did not deploy. She did not lose consciousness.

Patient denies nausea, vomiting, constipation, diarrhea, chest pain or other.

PHYSICAL EXAMINATION: PERRLA. EOMI. Tongue and uvula midline. Thyroid not enlarged. LUNGS: Clear to auscultation and percussion. ABDOMEN: No mass, tenderness or flank tenderness. Bowel sounds present within normal limits.

RANGES OF MOTION: Lumbosacral spine flexion 60, extension 2, right side bending 8, left side bending 10, right rotation 14 and left rotation 14. Cervical spine ranges of motion are full but with pain at the extremes.

RADIOGRAPHS: Previous films of the right hand were unremarkable.

DIAGNOSTIC STUDIES: MRI of the cervical spine revealed partial dehydration of the discs with mild narrowing of the disc spaces.

ASSESSMENT:

1. Cervical sprain and myositis with partial dehydration of the discs and mild narrowing of the disc spaces throughout the cervical spine.

2. Thoracic sprain and myositis, rule out disc injury.

3. Lumbar sprain and myositis, rule out disc injury.

4. Sciatic neuritis.

5. Cervicogenic syndrome.

6. Cervicogenic headaches.

PLAN: Continue current therapy with beginning emphasis on ranges of motion and strengthening. MRI of the thoracic and lumbar spine.

David Cheesman, D.O.

DC/C&C/kc

JANE DOE

–

PROGRESS NOTE -

S: Jane complains of headaches occurring approximately three times per week at a pain level of about 5-6. Cervical spine level is rated at 5-6. Thoracic spine very minimal 0-2 and most of the time not painful. Lumbosacral spine denies pain. Has some left arm pain occasionally in certain positions. Denies any sciatic type pain. Patient is due to see her primary care physician today and she has been feeling a little sick to her stomach lately and was prescribed Phenergan by the primary care physician. I have discussed with Jane at length the limitations of our scope of practice here are prickly musculoskeletal injury and that she should follow-up with her other doctors for medical and other problems.

O: Temp 98.2. Pulse 70. Respiration 16. BP 124/80. MRI of 01/23/4567 revealed cervicothoracic levoscoliosis. Incidentally, there is noted a high T2 signal intensity lesion in the left lobe of the thyroid measuring approximately 2.7 cm AP dimension and 2.1 cm transverse dimension.

Radiologist recommended further evaluation ultrasound. Ranges of motion: Lumbosacral flexion full, extension full, right rotation full, left rotation full, right side bending full and left side bending full with pain at the extremes of all of these ranges of motion. Cervical flexion 30, extension

4, right rotation full but with pain at extremes, left rotation full with pain at extremes, right side bending 10 and left side bending 10.

A:

1. Spondylosis of the thoracic spine as per x-ray study of 01/23/4567.

2. Bony structures intact right shoulder as per x-ray study 01/23/4567.

3. No bony injury left shoulder as per x-ray study 01/23/4567.

4. Cervical spine anterior spondylosis at C4-5 level as per x-ray study 01/23/4567.

5. Narrowing of the C5-C6 disc space as per x-ray study 01/23/4567.

6. Thyroid lesion as per MRI of 01/23/4567. Rule out neoplasm. Rule out other.

7. Cervicothoracic levoscoliosis as per MRI study of 01/23/4567.

8. Cervical sprain and myositis.

9. Chronic thoracic sprain and myositis, resolved.

10. Lumbosacral sprain and myositis resolved.


P: I have advised the patient that she should follow with her family physician regarding the lesion in the thyroid and also regarding other medical problems including the feeling of nausea she has had during the past week or so. She is to see that physician today. I have further advised Jane that she should follow with an orthopedist regarding her left shoulder injury.


DC/C&C/kc

JANE DOE

–

MMI REPORT

Jane Doe is an African-American female born 01/23/4567 involved in a motor vehicle accident in 12/3456. At that time, she was sitting still in a vehicle that was impacted from the rear while waiting at a stop light. Patient first experience pain immediately after the accident and continued to suffer headache, neck and shoulder pain.

Ranges of motion were less than normal throughout the course of her treatment and that the time of the last visit the headaches were occurring approximately three times per week at a pain level of 5-6. Cervical spine pain was 5-6. Thoracic spine pain was 0-2. Lumbosacral pain was nonexistent. There was some pain radiating into the left arm in certain positions. There was no compl i of s a i pa n.

The pa i nt be n xpe i nc ng ome mi us a s oma h s ” and had been given a prescription for Phenergan from her family physician. It was also noted incidentally on an MRI study that a thyroid lesion was present. The patient was advised to followup with the family physician on the same day she was last seen which was 12/34/5678. Patient is to follow with OB/GYN, primary care physician as well as orthopedist, neurologist and possibly algologist. Patient does not wish to have further studies so we are precluded from further imaging the thoracic spine or skull for possible intracranial lesion or other.

ASSESSMENT:

1. Cervical sprain and myositis.





6. Thyroid left lobe lesion, rule out neoplasm (patient is also to follow with an endocrinologist).

7. Impingement with apparent partial thickness tear of the supraspinatus tendon with no gross labral tear as per MRI 01/23/4567. Plain films of the left and right shoulder were unremarkable.

8. Thoracic spine films revealed spondylosis.

9. C5-C6 disc space narrowing without herniated nucleus pulposus.

10. Anterior spondylosis level C4-C5.

11. Cervicothoracic levoscoliosis as per MRI of 01/23/4567.

IMPAIRMENT RATING: Based on the soft tissue injuries as above and in light of the disc space narrowing as shown by films of the cervical spine and also based on the apparent supraspinatus tear of the shoulder and given the persistence of patients symptoms and problems I would rate this patient's permanent impairment based on the AMA Guides to Permanent Impairment, fifth edition, orthopedic section at 8%.

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JANE DOE

PROGNOSIS: This patient has medical problems, which should be followed above, and we have also discussed the necessity for her to follow up with an endocrinologist, her primary care physician, OB/GYN physician, dermatologist for full skin screening on a regular basis and an orthopedist in neurologist regarding ongoing pain and possible surgery for the shoulder. She will undoubtedly require care in the future and I estimate this care to be approximately 15

–

25 sessions per year ranging in cost from $100 per visit to $300 per visit. Fifteen visits at $100 each would be $1500. Twenty five visits at $300 each would be $7500. Right shoulder is weak and without surgical repair, the patient will be quite limited as to the work she can do in the future. It would be a good idea to consider occasional retraining as part of her future plans. Education cost for these would vary per profession and school chosen.


DC/C&C/kc

JANE DOE

The patient is a Hispanic female born 01/23/4567 who was in a motor vehicle accident on

01/23/4567. The patient states that a vehicle running a stop sign impacted with the right front of her vehicle. Her vehicle was airbag equipped in the vehicle was totaled. She did lose consciousness and she was wearing a seatbelt. She was taken to the emergency room by ambulance. Studies were done there but these are not available at this time. We will attempt to get these records.

PAIN RATINGS: Headaches were occurring on a daily basis immediately subsequent to the accident. Now they are occurring approximately three times per week and are rated at a level of eight. Cervical spine pain is mostly on the right side and at a level of nine according to the patient. Thoracic pain is also at a level of nine. Lumbosacral pain eight.

The patient states her right leg is weak and left arm is weak. She also has some pain in the right arm in certain positions. Also has some right sciatic type pain if she lies down or sits for too long.

MEDICATIONS: Pain medications were prescribed at the emergency room and also patient has taken ibuprofen. Patient cannot remember the name of the pain medication. She will bring the same in for the future.

FAMILY HISTORY: Mother living age 80 and in good health. Father deceased age 60 due to unknown causes. One brother and seven sisters all in apparent good health.

PAST MEDICAL HISTORY: Denies.

ALLERGIES: Denies.

PAST SURGICAL HISTORY: Denies.

REVIEW OF SYSTEMS: HEENT: Denies loss of vision, hearing, sense of taste, smell or other. Cardiorespiratory: Denies angina, dyspnea, palpitations or other. Gastrointestinal: Denies nausea, vomiting, constipation or diarrhea. Genitourinary: Denies hematuria, dysuria or pyuria.

Endocrine: Denies history of diabetes mellitus, thyroid problems or other. Skin: Denies history of melanomatous lesions or other. Neuropsychiatric: Denies use of tranquilizers, antidepressants or other.

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JANE DOE

PHYSICAL EXAMINATION:

VITALS: Temp 98.2. Respirations 16. BP 110/68. Pulse 64.

HEENT: PERRLA. EOMI. Tongue and uvula midline. Thyroid not enlarged. THORAX:

HEART: Regular rhythm and rate. LUNGS: Clear to auscultation and percussion. ABDOMEN:

No mass, tenderness or flank tenderness. Bowel sounds present within normal limits. No other pathology found. GENITOURINARY: Patient prefers to defer genitourinary for regular

OB/GYN physician. SKIN: Patient prefers to defer full skin examination for regular dermatologist. MUSCULOSKELETAL: Ranges of motion are decreased for both lumbar and cervical spine.

ASSESSMENT:


2. Cervical sprain and myositis, rule out disc injury.


4. Lumbosacral sprain and myositis, rule out disc injury.


PLAN: Imaging studies have been ordered of the cervical spine and thoracic spine. Will recheck in two weeks. Patient to return sooner if worse. Will continue therapy at current level.


DC/C&C/kc

JANE DOE

Patient is a Hispanic female born on 01/23/4567 who was in a motor vehicle accident on

01/23/4567. At that time she was the front seat passenger in a Chevrolet S10 pick up 1994, which was struck from the rear first by a large car or truck, patient cannot remember exactly which, and then another vehicle to make and model of which she cannot recall. Her vehicle was then propelled into a small car in front of her resulting in a four car accident and resulting in her car being totaled. The truck in which she was driving was not airbag equipped and she was wearing a seatbelt. She believes she was stunned as she has poor recall of the exact accident so apparently there was some possible temporary loss of consciousness or temporary disorientation. She was taken to the emergency room by ambulance and was discharged the same day. Several x-ray studies were done and three-dimensional imaging was also apparently done. We are attempting to obtain the records from same.

PAIN RATINGS: Headaches are occurring every day at a level of eight. Cervical spine pain is rated at eight. Thoracic spine pain is rated at eight. Lumbosacral spine pain is rated at seven.

There is some radiation of pain into the arms especially in certain positions with the left being the worst. Patient denies any leg pain.

MEDICATIONS: Tylenol as needed, lisinopril 40 mg one daily, isosorbide dinitrate 50 mg 1 daily, Advair and Singulair for asthma.

FAMILY HISTORY: Mother deceased age 72 due to myocardial infarction. Father deceased age 73 due to myocardial infarction. Patient has had nine siblings. Seven are living. Two were killed in motor vehicle accidents. Of the surviving siblings, all are in good health.

PAST MEDICAL HISTORY: Patient has had two previous episodes of chest pain and was evaluated in hospital and subsequently released. Mammography was performed approximately one year ago and was within normal limits. She has not had any pap smears since the 1997 hysterectomy.

ALLERGIES: Denies any medication allergies.

PAST SURGICAL HISTORY: Patient had breast biopsy in 2001, which was benign. Patient does have a history of fibrocystic breast disease. Patient also relates an episode of removal of a skin cancer of unknown type in 2001. It is unclear whether this was a melanoma or some other type of cancer. We are attempting to obtain the old records. Patient had an abdominal hysterectomy in 1997. One ovary was left. She denies other surgeries.

PAST TRAUMATIC HISTORY: Denies.

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JANE DOE


Musculoskeletal: Denies decreased range of motion and joint pain except as mentioned above.

Endocrine: Patient was advised that she might be prediabetic at one time and was given some oral medication, which he never took. Fasting blood sugar was 124 today. This is being treated by her family physician. Skin: See above. Denies other. Neuropsychiatric: Denies use of tranquilizers, antidepressants or other.





No mass, tenderness or flank tenderness. Bowel sounds present within normal limits. No other pathology found. GENITOURINARY: Patient prefers to defer genitourinary for regular family physician. SKIN: Patient prefers to defer full skin examination for regular dermatologist or regular family physician. MUSCULOSKELETAL: Ranges of motion are as follows: Lumbosacral forward flexion 15, extension two, right side bending four, left side bending four, right rotation six, left rotation four. Cervical spine forward bending 24, extension 2, right side bending 14, left side bending 10, right rotation 12 and left rotation 12. Grip and dorsi flexion equal and normal bilaterally.

ASSESSMENT:






PLAN: Will continue daily therapy for one more week and if possible will reduce to three times per week subsequent to same. Patient is to return in two weeks for further evaluation with me in return sooner if worse.


DC/C&C/kc

JOHN DOE

–

PROGRESS NOTE

This is a Hispanic male born on 01/23/4567 who was in a motor vehicle accident on 01/23/4567.

He was driving a Chevrolet S10 pick up 1994, which was struck, from the rear by a large car or truck in and subsequently by another vehicle propelling his vehicle into a small car in front of him. His vehicle was not airbag equipped. He was wearing a seatbelt. He does not believe he lost consciousness however, he has poor memory of the accident and apparently was stunned. He was taken to the emergency room via ambulance. Numerous x-ray studies were performed and apparently, there might have been some three-dimensional imaging. We are attempting to obtain the records of same.

PAIN RATINGS: Headaches were occurring every day at first but now are only occurring two to three times per week at a level of four. Cervical spine pain six. Thoracic pain six. Lumbosacral pain zero. Arm pain radiation occurs into the shoulders and into the arms with the left being the worst especially in certain positions. There was some leg pain radiation at first but this has since resolved.

MEDICATIONS: Advil for pain and lisinopril 40 mg 1 daily for high blood pressure.

FAMILY HISTORY: Mother deceased age 38 in child birth. Father deceased age 69 due to diabetes mellitus. Patient apparently has 23 siblings, 17 of which have been killed leaving six living and in apparent good health.


ALLERGIES: Denies.

PAST SURGICAL HISTORY: Right inguinal hernia repair seven years ago.



Musculoskeletal: Occasionally prior to the accident, he had sore shoulders bilaterally but, this has increased markedly since the motor vehicle accident. Endocrine: Denies history of diabetes mellitus, thyroid disorder or other.. Skin: Some questionable lesion in the right zygomatic area.

Denies other. Neuropsychiatric: Denies use of tranquilizers, antidepressants or other.

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JOHN DOE





No mass, tenderness or flank tenderness. Bowel sounds present within normal limits. No other pathology found. GENITOURINARY: Patient prefers to defer genitourinary for regular family physician. SKIN: Patient prefers to defer full skin examination for regular dermatologist.

MUSCULOSKELETAL: Ranges of motion are as follows: Lumbosacral forward flexion 20, extension 2, right side bending 12, left side bending 12, right rotation 6, left rotation 8. Cervical spine forward bending full, extension full with pain at extreme and all other parameters full range of motion with pain at extremes.

ASSESSMENT:



3. Thoracic sprain and myositis, rule out disc injury




PLAN: Patient is to continue therapy on a daily basis for another week and then we will hope to decreased therapy to three times per week. Patient is to see me again within two weeks in return sooner if worse.


DC/C&C/kc

JANE DOE

Patient is a Hispanic female born on 01/23/4567 who was in a motor vehicle accident on

01/23/4567. Patient was driving in 1995 Acura, which was struck, from the rear by an SUV, a large Ford Excursion, which was in turn struck by a Dodge four-door car. The patient vehicle was airbag equipped. They did not deploy. She did not lose consciousness. She was wearing a seatbelt. She did not go to the emergency room. She has experienced some sleep interference.

Usually wakes up about 4:30 a.m. in pain and stiffness.

PAIN RATINGS: Headaches were occurring every day at first but subsequent to acupuncture treatment, they have decreased to approximately every other day. They are tension type in the pain rating is 4-5. Cervical spine is stiff but not truly painful. Thoracic spine pain rating 5. Lumbosacral pain rating 4 with right sciatic type pain. She experiences increased pain on the commode and I have advised her to get a cushion for support to build up the commode so she will not have to flex so much from the lumbosacral spine when sitting on the commode.


MEDICATIONS: Denies.

FAMILY HISTORY: Father deceased age 77 due to myocardial infarction. Mother living age

75 and in good health. Has two brothers also in good health.

ALLERGIES: Patient states when she takes penicillin she passes out. States she tends to be a

“ ow pr s ur pe s a ppa nt hi r a s hoc ua i She de s he a l gies.

PAST SURGICAL HISTORY: C-section 1984. Denies other.

PAST TRAUMATIC HISTORY: Ankle sprains in high school subsequent to playing volleyball and basketball. Denies other.

REVIEW OF SYSTEMS: HEENT: Denies loss of vision, hearing, sense of taste, smell or other. Cardiorespiratory: Denies angina, dyspnea, palpitations or other. Gastrointestinal: Has had some loss of appetite since the motor vehicle accident but slight tendency to diarrhea but has seen no blood in the stool or other. Genitourinary: Denies hematuria, dysuria or pyuria. Musculoskeletal: Complains of pain as mentioned above. Denies other. Endocrine: Denies history of diabetes mellitus, thyroid disorder or other.. Skin: Denies melanomatous or other lesions.. Neuropsychiatric: Denies use of tranquilizers, antidepressants or other.



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JANE DOE



No mass, tenderness or flank tenderness. Bowel sounds present within normal limits. No other pathology found. GENITOURINARY: Patient prefers to defer genitourinary for regular

OB/GYN physician. SKIN: Patient prefers to defer full skin examination for regular dermatologist or family physician. MUSCULOSKELETAL: Ranges of motion are as follows: Lumbosacral forward flexion 72, extension 4, right side bending 14, left side bending 16, right rotation 10, left rotation 10. Cervical spine full range of motion but with pain at extremes.

ASSESSMENT:




PLAN: Will continue current therapy on a daily basis for another seven days and then hope to decreased therapy to approximately three times per week. Patient is to follow-up with me in another two weeks and to return sooner if worse. Patient is to obtain all medical records from the emergency room and other physicians and to bring them for her record in for evaluation here.


DC/C&C/kc

JOHN DOE

–

09/22/2005

Patient is a 48-year-old Caucasian male with a history of hypercholesterolemia, high blood pressure, gastroesophageal reflux disease and diverticulitis.

MEDICATIONS: Pravachol 40 mg 1 daily, Aciphex 20 mg 1 a.m. before meals, Advair discus

100/50 as needed, albuterol inhaler as needed, BuSpar 15 mg 1/3 tablet a.m. PRN.

PAST MEDICAL HISTORY: Hypercholesterolemia, essential hypertension, diverticulitis with flare up two years ago and two to three subsequent flare ups which were more easily controlled, asthma diagnosed approximately 15 years ago, gastroesophageal reflux disease, borderline diabetes mellitus. Patient states he treats irritable bowel syndrome with a liquid diet when it flares up. Currently he is on the South Beach Diet to reduce cholesterol and weight.

PAST SURGICAL HISTORY: Colonoscopy approximately three years ago. Denies other.

PAST TRAUMATIC HISTORY: Left clavicle fracture approximately 20 years ago while playing hockey.

Regular pharmacy (123) 456-7890.

FAMILY HISTORY: Mother living with pre senile dementia age 84. Mother has one sibling with cancer. Father deceased age 83 due to myocardial infarction. One sister deceased at age 54 due to fatty liver and possible lithium overdose. One sister with high blood sugar and high cholesterol age 57.

REVIEW OF SYSTEMS: HEENT: Wears eyeglasses. Has been recently evaluated at the

Dough Eye Institute and might be suffering from borderline glaucoma but so far intraocular pressures have been within normal limits. Cardiorespiratory: Negative except as mentioned above and. Gastrointestinal: Negative except as mentioned above. Genitourinary: Denies hematuria, dysuria or pyuria. Musculoskeletal: Denies decreased range of motion or other except at feet.

Feet hurt somewhat on arising in the ankles and the metatarsal areas. Endocrine: Denies history of thyroid disorder or other except for questionable borderline diabetes mellitus. Skin: Denies melanomatous or other lesions.. Neuropsychiatric: Had taken Zoloft but it reduced libido to the point where it needed to be changed to BuSpar as mentioned above. Denies other..



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JOHN DOE

HEENT: Patient wears eye glasses. PERRLA. EOMI. Tongue and uvula midline. Thyroid not enlarged. Fundi within normal limits. No other pathology found. THORAX: HEART: Regular rhythm and rate. LUNGS: Clear to auscultation and percussion. ABDOMEN: No mass, tenderness or flank tenderness. Bowel sounds present within normal limits. No other pathology found.

GENITOURINARY: Patient prefers to defer genitourinary for urologist. SKIN: Patient prefers to defer full skin examination for regular dermatologist. MUSCULOSKELETAL: Ranges of motion are full in all extremities. Grips and dorsi flexion equal and normal bilaterally upper and lower. Neuropsychiatric: Alert and oriented x3. Denies homicidal or suicidal ideation. DTRs equal and normal bilaterally in the upper and lower. No other pathology found.

ASSESSMENT:

1. Essential hypertension per history.

2. Hypercholesterolemia per history.

3. Diverticulitis per history.

4. Gastroesophageal reflux disease per history.

5. History of possible elevated serum glucose levels, rule out diabetes mellitus.

6. Stress and anxiety, mild.

7. History of asthma (diagnosed 15 years ago), well-controlled with minimal medication.

PLAN: The patient states he used to run marathons but has been unable to do that because of the occasional foot pains. I have advised in lite course of weight training and walking as well as swimming slowly building to higher levels as tolerated. Patient to return in one week for further evaluation and to bring all medical records. Patient to return sooner if worse. Patient advises that he is being switched by his family physician from his current blood pressure medication to verapamil SR 180 mg one p.o. at h.s. and also for hypertension lisinopril apparently 20 mg one p.o.

q.d. and apparently Mevacor 40 mg one p.o. at h.s. He is currently being treated by John Dough,

D.O. and Jane Dough, ARNP at the family practice, 123 Main St., Anywhere, US 12345


DC/C&C/kc

JOHN DOE

This is a Hispanic male born on 01/23/4567 who was in a motor vehicle accident on 01/23/4567.

The patient was the driver in a vehicle, which was hit from the rear. He was driving a 1996 Nissan Maxima which was airbag equipped with the airbag did not deploy. There was approximately $1000 damage done to his vehicle. He was wearing a seatbelt. The vehicle, which hit him, was a Chrysler sedan. He did not go to the emergency room and he experienced pain in the next day and saw a doctor a few days later.

PAIN RATINGS: Patient states he did have some decreased auditory acuity for approximately two to three days subsequent to the accident but this has since resolved. Cervical spine pain rating 2-3. Thoracic pain denies. Lumbosacral pain denies.



FAMILY HISTORY: Mother living age 55 in apparent good health. Father living age 50 and in good health. Three brothers and two sisters all in apparently good health.


ALLERGIES: Denies.




Musculoskeletal: Denies decreased range of motion or joint pain or other except as mentioned above. Endocrine: Denies history of diabetes mellitus, thyroid disorder or other.. Skin: Denies melanomatous or other lesions.. Neuropsychiatric: Denies use of tranquilizers, antidepressants, institutionalization or other.


VITALS: BP 116/70. Pulse 60. Respiration 14. Temp 98.0

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JOHN DOE


HEART: Regular rhythm and rate. No clicks or murmurs. No other pathology found. LUNGS:

Clear to auscultation and percussion. ABDOMEN: No mass, tenderness or flank tenderness.

Bowel sounds present within normal limits. No other pathology found. GENITOURINARY: Patient prefers to defer genitourinary for regular urologist. SKIN: Patient prefers to defer full skin examination for regular dermatologist or family physician. MUSCULOSKELETAL: Ranges of motion are as follows: Lumbosacral forward flexion 80, extension , right side bending, left side bending, right rotation and left rotation all have full range of motion. Cervical spine full range of motion but with pain at extremes.

ASSESSMENT:


2. Thoracic sprain and myositis.

3. Lumbosacral sprain and myositis, resolved.

PLAN: Continue therapy one time per week. Patient to return in one week for further evaluation and return sooner if worse.


DC/C&C/kc

JANE DOE

Patient is a Hispanic female who was involved in a motor vehicle accident on 01/23/4567.

PAIN RATINGS: Currently pain ratings are as follows: headaches occur every day in the occipital area at a level of 6, cervical spine 6, thoracic spine 8, and lumbosacral spine 9. Patient complains of some left arm pain especially in certain positions.

PHYSICAL EXAMINATION: HEART: Regular rate and rhythm. LUNGS: Clear to auscultation and percussion. PERRLA. Alert and oriented x3. Denies homicidal or suicidal ideation.

Lumbosacral forward flexion full with pain at extreme, extension 1, right side bending 8, left side bending 6, right rotation 6, left rotation 10. Cervical spine ranges of motion are full with some of her back pain initiated by cervical spine ranges of motion and also pain in the cervical spine itself at the extremes of motion.

ASSESSMENT:






PLAN: Patient tried to reduce therapy to once or twice per week but that made her worse so we will increase therapy back to five times a week for a brief period in hopes of increasing the intensity and frequency and duration of therapy so the patient will recover more quickly. I have requested a lumbosacral MRI. Will request other imaging if needed. Patient is to follow with me within two weeks and return sooner if worse.


DC/C&C/kc

JANE DOE

Patient is a Caucasian female born on 01/23/4567 who was in a motor vehicle accident on

01/23/4567. She states she was the driver in a vehicle, which was stationary when it was impacted from the rear by another vehicle. She was driving a Toyota Forerunner to which approximately $1500 damage occurred. The other vehicle was an Elantra. Her vehicle was equipped with the airbags. They did not deploy. She was wearing a seatbelt. She did not go to the emergency room. She saw a physician approximately one week later. She had worked out quite vigorously that day and was not sure whether the soreness was due to the worked out for the accident. However, as the pain and suffering continue to increase she felt she was compelled to see a physician for evaluation and possible therapy.

PAIN RATINGS: Headaches are occurring approximately every other day rated at 7. Cervical spine pain is rated at 7, this radiates into the shoulders and the arms to a degree. Thoracic pain is rated at 8 and lumbosacral pain is rated at 8. There is also some left sciatic pain and paresthesias.

MEDICATIONS: Patient takes birth control pills (Ortho Novum 777) and has been taking same for approximately nine months. She denies other.

FAMILY HISTORY: Father living age 59 and in good health. Mother living age 47 with a history of melanomatous skin lesions. Has one brother also in good health.

PAST MEDICAL HISTORY: Tonsillectomy and adenoidectomy as a child. Wisdom teeth extraction. Denies other surgery.

ALLERGIES: Penicillin causes abdominal pain. Patient states she must eat a large meal prior to taking penicillin or the pain is extreme. Latex causes rash and itching.



REVIEW OF SYSTEMS: HEENT: Denies loss of vision, hearing, sense of taste, smell or other. Cardiorespiratory: Was diagnosed with asthma but has not required any medication for over six years. Gastrointestinal: Denies nausea, vomiting, constipation or diarrhea. Genitourinary: Denies hematuria, dysuria or pyuria. Musculoskeletal: Denies decreased range of motion or joint pain or other except as mentioned above and denies any problems prior to the motor vehicle accident. Endocrine: Denies history of diabetes mellitus, thyroid disorder or other.. Skin:

Denies history of melanomatous lesions however, has had a couple of moles removed which were benign. Neuropsychiatric: Denies use of tranquilizers, antidepressants, institutionalization or other.



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JANE DOE




Bowel sounds present within normal limits. No other pathology found. GENITOURINARY: Patient prefers to defer genitourinary for regular family physician or OB/GYN. SKIN: Patient prefers to defer full skin examination for regular dermatologist or family physician.

MUSCULOSKELETAL: Full range of motion in extremities. Lumbosacral forward flexion 80, extension 1, right side bending 6, left side bending 6, right rotation 8 and left rotation 10. Cervical spine full range of motion in all parameters however, there is some pain at the extremes of range of motion, particularly with right rotation, left rotation and right and left side bending.

ASSESSMENT:






PLAN: If pain and symptoms persist for more than another week we may need to consider imaging studies.

So far, according to the patient, no imaging studies have been performed.

Patient is to avoid heavy lifting and to return sooner if worse for evaluation. In the meantime, we will try to treat her on a daily basis fairly intensively for this week in the hope that the symptoms will resolve and that further expense and imaging will not be necessary.


DC/C&C/kc

JOHN DOE

Patient states his vehicle was impacted from the rear by another vehicle and propelled into the back of the vehicle in front of him. He was driving a minivan. The vehicle, which impacted his vehicle, was in 1986 Lincoln and the vehicle into which he was propelled was a pickup truck.

He denies loss of consciousness. He did not go to the emergency room. He was wearing a seatbelt. He experienced pain immediately subsequent to the impact. He saw a doctor the next day.

PAIN RATINGS: Headaches denies. Cervical spine pain 6. Thoracic pain and denies. Lumbosacral pain 7. Patient was having some mild dizziness but this seems to have resolved.


FAMILY HISTORY: Mother living age 69 with high blood pressure. Father living age 72 with prostate complaints and is due for surgery. Has five brothers and one sister all in apparent good health.


ALLERGIES: Denies.

PAST SURGICAL HISTORY: Has had a total of 12 surgeries in the past as a result of trauma secondary to sports activities while living in Colombia. He has had surgeries on his nose, arms, ankles, knees and other.

PAST TRAUMATIC HISTORY: No other motor vehicle accidents and no other trauma except as mentioned above.


Musculoskeletal: Denies except as mentioned above and denies any problems prior to the motor vehicle accident. Endocrine: Denies history of diabetes mellitus, thyroid disorder or other. Skin:

Denies history of melanomatous lesions or other. Neuropsychiatric: Denies use of tranquilizers, antidepressants, institutionalization or other. Denies homicidal or suicidal ideation.



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JOHN DOE




Bowel sounds present within normal limits. No other pathology found. GENITOURINARY: Patient prefers to defer genitourinary for regular family physician. SKIN: Patient prefers to defer full skin examination for regular dermatologist or family physician. MUSCULOSKELETAL:

Ranges of motion are full for the lumbosacral spine but there is pain at the strains of range of motion especially on the right side with extension, right side bending and right rotation. Cervical spine range of motion is also full but there is pain at the extremes.

ASSESSMENT:



3. Thoracic sprain and myositis, resolving.


PLAN: Because of the pain and symptoms, persist in for nearly two months imaging studies will be performed. Patient is to return within a week for reevaluation by me and in the meantime continue his current care and therapy at the current rate. Patient is to return sooner if worse.


DC/C&C/kc

DAVID CHEESMAN, DO

9/22

KC92231A

JANE DOE

JANE DOE

JANE DOE

JANE DOE

JANE DOE

JANE DOE

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JOHN DOE

JANE DOE

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JANE DOE

JANE DOE

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JOHN DOE

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599734

599737

599740

599744

599750 (INCOMPLETE)

599756

599761

599763

599766

599769

599771

599773

599785

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599789

JANE DOE - C&C Transcription, Inc.

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