Personal Injury Example
ABC Psychiatric Services, P.A.
Dr. G W
Tuesday, March 17, 2009
Dr. W in his letter to Dr. R has stated that claimant was seen for a psychiatric
evaluation at the request of Mr. M (attorney). The purpose of the evaluation was to
assess his psychiatric condition secondary to his auto accident of 1/31/09.
Transcripts of this doctor state that claimant has been injured in 5 auto accidents.
Claimant was unable to date the first two but thinks they occurred in 2007. He injured
his shoulder in one of them. Claimant pointed out that he was not charged by police
as being at fault in any of them but each one served to exacerbate problems from
the one before.
In August 2008 he was hit from the rear. He sustained two impacts in that accident
when his vehicle was pushed into another car. On 10/12/08 he was driving on USA
Road, was in the turn lane going into the K Hall when he was again hit from the rear
by a truck going about 60 mph. He sustained injury to his knees and wrist and later
developed visual problems. On 1/31/09 he was stopped in traffic on Highway 1 and
was hit from the rear sustaining considerable damage to his truck and exacerbation
of injuries from previous accidents.
Claimant owns a business dealing in mechanical construction. His jobs include
maintaining air conditioners totaling more than 30 tons. He is no longer able to do
the work because of his various injuries including a visual problem, dizziness and
pain in his back and wrist. Despite a bad economy, his business is doing well.
However, he is unable to get out and obtain new contracts because he feels
depressed and has little initiative since the last few accidents. He stated: "I don't
understand why people can get away with harming me." He is infuriated and
depressed much of the time. His mother's recent death aggravated the situation.
Notes also mention that claimant’s brother was brutally murdered in 1974. He moved
to Florida to put the gruesome memories behind him. He felt he had achieved his
goal until recently when his guilt resurfaced for not having been there to somehow
protect his brother.
He speaks rapidly and delivered his account of accidents, his work, insomnia, loss of
sexual desire and loss of control of his body in machine-gun like fashion. I could not
keep up with him in spite of interrupting him and trying to write all that he told me. He
was both anxious and angry. He complains that he feels he has lost control of his life
and is upset that people who are supposed to help him seem to move in slow
motion.
Diagnostic Impression:
Axis I: 309.81 Posttraumatic Stress Disorder
Axis II: none known
Axis 111: Macular damage NOS, Injuries to left ring finger NOS
Axis IV: Psychosocial Stressors include insomnia, impaired attention and
concentration, loss of sexual desire, shoulder and back pain, irritability, pain and
anxiety; #5 - Severe
1|Page
Axis V: Current Global Assessment of Functioning (GAF) = 40 Highest GAF in
the past year = 60
Dr. W opined that claimant is in need of psychotherapy to adequately understand
what is happening to him and hopefully become less symptomatic. The prognosis is
guarded. Within a reasonable degree of medical certainty doctor said that claimants
current symptoms seem to be related to the recent motor vehicle accidents. The
trauma of the recent car accidents has also served to exacerbate severe distress
related to his brother's murder in 1974. He is to return in the near future to begin
psychotherapy.
R Chiropractic, Inc.
Dr. G R
Date: 03/12/09
Dr. R has opined that claimant’s present medical condition is causally related to
injury and accident that occurred on 10/12/08. The impact the patient received
during the accident caused damage to the neck and low back. This accident has
also caused visual problems.
As a result of the accident patient did suffer aggravation of an existing condition or
physical defect and that with regards to the patient’s neck and low back pain, only
50% or less was preexisting.
Doctor also opined that as a result of the accident claimant did suffer from significant
and permanent loss of an important bodily function and other than scarring and
disfigurement, patient did suffer from a permanent injury.
Dr. R also stated that Mr. M (claimant) was involved in another MVA on January 31,
2009. This second accident occurred while Mr. M was still under treatment from the
October 2008 MVA, so he was not at MMI at the time of the January 31, 2009
accident. He was however approximately 80-90% of the way to having reached MMI
with regards to the injuries sustained in the October 12, 2008 MVA.
Regarding whole body Permanent Partial Impairment under the A.M. A. guidelines,
the portion of impairment that is attributable to the October 12, 2008 MVA, that
portion is 12.0% W.P. permanent partial impairment. Doctor has however pointed out
that above this patient's permanent partial impairment is the ways in which this
gentleman's injuries have caused limitations in his activities of daily living. Due to
injuries sustained in this accident there are many tasks/activities that Mr. M can no
longer perform at work. Mr. M owns an air conditioning/heating business that
performs installation and repairs on home and commercial AC/Heat units. Claimant
states that he can no longer go up ladders, climb around in attics, lift heavy objects,
dig or crawl; all things he says he used to do before this accident occurred. At home
he finds it difficult to get comfortable to even sit and read a book or do regular
household chores. Dr. R further mentioned that one must take in to consideration not
only the percentage of impairment that Mr. M has sustained due to this accident but
how it has also changed his lifestyle and affected his quality of life.
Dr. R in his letter dated 09/12/06 to R H of Auto Owner has stated that Mr. M
was the restrained driver of a 2005 Dodge Dakota pick up truck, which was involved,
in a vehicular collision on September 4, 2006. The vehicle he was driving was at a
complete standstill North bound on Zakonni Road at Injury Blvd. when he was
2|Page
unexpectedly struck from the rear by a Ford SUV. He says after the first vehicle
struck his car from the rear, another vehicle ran into that car pushing it his car,
therein causing a second impact. As a result of the impact Mr. M says he was
thrown forward inside his vehicle, he states that his right leg and knee struck the
dashboard and he complains of pain in the knee ever since. The police were
dispatched to the accident scene and the driver that first struck Mr. M’s vehicle was
cited for the accident. Since the accident Mr. M complains of on-going dizziness with
some slight blurred vision. After the collision, Mr M experienced pain in the neck,
back, shoulders and right knee.
Mr. M has been involved in other motor vehicle accidents. He was treated in this
office for injuries associated with an automobile accident which occurred on or about
12/13/05. He had similar complaints of neck pain, right shoulder pain and low back
pain associated with that accident. He was treated for these injuries and released
from active care in April 2006. He did not appear to have sustained any permanent
injuries as a result of that accident.
Occupational History: Mr. M is an air conditioning contractor. He states that he has
not missed any work since the time of the accident, but states he does have
problems lifting even light objects, has problems driving and he can't climb a ladder.
Initial Chief Complaints
1. Constant headaches in the occiput and temples bilaterally. The headache is
described as a constant ache and rates the intensity as a 5 (scale of 0-10, 0
being no pain, 10 being excruciating). He complains of sharp pain which
rates as a 7-8 with quick movements. Associated with the headaches are
blurred vision and the appearance of a halo around objects. Tylenol and
Alleve ease the headaches some.
2. Constant neck pain bilaterally from the subocciput to the cervicothoracic
region and into the trapezius muscles bilaterally. He describes the pain as a
constant ache which he rates as a 5 (scale of 0-10, 0 being no pain, 10 being
excruciating), and again says that certain movements of the head and
activities such as driving and getting out of the chair cause increased pain, to
an 8-9 (scale of 0-10). Pain also radiates into the right upper thoracic region
to approximately T3/T4.
3. Mr. M says that his xiphoid process has been dislodged anteriorly since the
accident and lifted his shirt to show me. I do not recall seeing this
abnormality when he was coming in for treatment last year. So this does
appear to be a new problem.
4. Mr. M says he has no strength in the right knee, "it's very weak". Says he
can't extend it out. He also says that it's very swollen and inflamed and red
upon first awakening. He says the knee clicks every time he steps, especially
in the morning. Claimant also complains of pain in the medial right thigh to
the knee cap and pain at the medial and lateral patella. Patient says it's a
constant ache with sharp pain when he moves the leg, or twists. He says he
has to be very careful with what he does because it gives way sometimes.
EVALUATION: Examination reveals an alert, cooperative 67 year old male with an
oral temperature of 97.6 degrees F, radial pulse of 54 bpm and left arm BP of
128/80. No carotid artery bruits were noted and the heart auscultated normal.
Neurological: Upper extremity reflexes all tested as a 2+, normal, and included
evaluation of triceps, biceps and brachioradialis. Upper extremity muscles all tested
as a 5+, normal on the left and a 4+ reduced on the right. Muscles that were tested
3|Page
included evaluation of: deltoids, biceps, triceps, wrist flexors/extensors and intrinsic
hand muscles.
Orthopedic: Foraminal compression in the neutral position was positive causing
increased pain in the in the neck from the occiput to the cervicothoracic region.
Maximal cervical compression test was positive bilaterally causing increased pain in
the entire neck. Cervical distraction test was negative.
Evaluation of right knee: adduction/abduction stress tests were negative,
anterior/posterior drawer tests were also negative but painful, patellar grind test was
negative; McMurrays test was positive causing pain and clicking on performance of
test. There was also obvious swelling and anteriorly and posteriorly at the right knee.
ROM and Palpation: Cervical range of motion measured as follows: flexion 60,
extension 30, right lateral flexion 18, left lateral flexion 26, right rotation 36 and left
rotation 36; all ranges of motion were painful.
DIAGNOSIS:
1. Acute cervical sprain/strain (847.0).
2. Acute thoracic sprain/strain (847.1).
3. Migraine headaches, post traumatic (346.1).
4. Intercostal neuralgia (353.8).
5. Sprain of right knee with possible meniscal tear (844.9).
DISCUSSION: Mr. M completed a neck and back disability questionnaire and scored
a 58 and 54 respectively as a result of this injury, which translates clinically to a
severe disability for both regions. The following are a few of the positive items that
Mr. M checked off on the questionnaires. Because of pain his normal sleep is
reduced by <50%. The pain comes and goes and is severe. He can concentrate fully
when he wants with fair degree of difficulty. He can not do most of his usual work. He
has severe headaches which come frequently.
BONE & JOINT DISEASE, ORTHOPAEDIC SURGERY
R K, MD., Randall M. Perreira, PA, RMP
Date: 11/13/06, 11/27/06, 12/20/06, 12/05/06, 01/15/07, 01/29/07, 02/12/2007
Transcripts of 02/12/07 state that claimant has a lot of soreness and achiness which
is really the inflammation associated with the arthritis as well as the pseudogout.
Certainly the arthritis is aggravated from the scope.
Notes of 01/29/2007 state that claimant was being followed up in regards to his
arthroscopy of his knee. There were findings of significant chondrocalcinosis that
caused significant effusion postsurgically. Examination found the claimant to be
improving in regards to his range of motion albeit though he is still having pain.
Notes of 01/22/2007 state that claimant was 3 days status post arthroscopy of the
right knee. He has significant chondrocalcinosis and he is in a lot of discomfort and
pain as a result of this with a very inflamed knee.
Notes of 01/15/2007 of Dr. R K state that claimant was referred by Dr. R for
evaluation of his right knee. Claimant injured his knee when he was involved in a
motor vehicle accident. It has really gotten worse in October with pain giving out,
4|Page
stiffness getting up and getting going, but when he walks, he has sharp pain and the
knee wants to give out particularly with twisting. He was seen and an MRI was
obtained.
Examination reveals significant discomfort along the medial and lateral joint line. He
can extend his knee fully and hyperextension causes significant pain. He has 1+ to 2
Lachman with soft endpoint.
Review of x-rays, plain films did reveal some medial joint line narrowing consistent
with osteoarthritis.
MRI reveals osteochondral defect and medial meniscal tear as well as anterior
cruciate ligament deficiency.
IMPRESSION: Osteoarthritis with medial meniscus tear and anterior cruciate
ligament deficiency with a traumatic chondral defect. Certainly he has some
osteoarthritis but his symptoms are all mechanical.
Notes further stated that given the fact that he is 67 years old with an anterior
cruciate ligament deficiency; he is not a candidate for reconstruction. The only real
option would be to consider a replacement. Claimant did not want to do something
that drastic. If he can get rid of the mechanical symptoms, he states that he can live
with the achiness understanding that arthroscopic surgery may not get rid of his
achiness and may not get rid of his pain. He may continue to have discomfort with
regard to his knee requiring replacement.
Notes of 01/19/07 of R K, MD. Mention that claimant had a right knee medial
meniscal tear, right knee arthroscopy.
Notes of C R, MD dated 12/20/2006 and 12/05/06 mention that claimant underwent
Facet injection, diagnostic and therapeutic left L3-4, L4-5, and L5-S1. Claimant had
a PRE/POSTOPERATIVE DIAGNOSIS of Low back pain.
SURGEON: It was further stated that claimant had a severe axial low back pain
following a motor vehicle accident. He is believed to have a facet sprain/strain injury.
He is indicated today for facet joint injection for the treatment of intractable low back
pain.
Notes of 11/27/2006 state that claimant has a history of a motor vehicle accident that
occurred in September of 2006. Apparently he was rear ended 2 separate times. The
second time apparently his knee went into the dashboard. Claimant returned back
basically with severe low back pain and what he describes as severe right knee
pain. He does have an MRI of his right knee. He also has an MRI of his lumbar
spine and cervical spine. Claimant described sharp, aching, tender pain in the low
back and severe pain in the knee. He did complete a Quadruple Visual Analog
Scale. At worst in the last month his pain has been 8/10, at least it has been 5/10,
on average in the last 2 weeks it has been 10/10. It seems to improve when he lies
flat on his back and seems to worsen when he stands or walks in his knee and his
back.
Claimant’s past medical history was positive for hypertension. Past surgical history
was positive for coronary artery bypass graft, bowel resection.
Physical exam found the claimant to have severe joint line tenderness in the right
knee. He had a lot of tenderness with McMurray maneuver in the right knee. He had
no real significant anterior or posterior drawer or medial or lateral instability.
5|Page
Dr. R stated that certainly there does appear to be an osteochondral defect.
Additionally he has a partial tear of his anterior cruciate ligament and a meniscal
tear.
On review of the MRI of his cervical spine, claimant did have some very small focal
disk protrusions. They are not mentioned on the radiology report. There was a focal
right disk protrusion at C5-6; it was on image 20 of 34. There was also a small focal
disk protrusion on the left at C6-7; it was on image 16 of 22.
I carefully reviewed the MRI of his lumbar spine. He does have what I would grade
as mild spinal canal stenosis.
Impression:
1. Medial meniscal tear in the right knee.
2. Osteochondral defect in the right knee.
3. Possible anterior cruciate ligament tear.
4. Severe low back pain, facet sprain/strain injury.
Notes of Dr. J R dated 11/13/2006 state that claimant presented to the office today
for 3 complaints; the cervical spine, the lumbar spine, and his right knee. They all
started at the same time. He believes it was either September 4, 2006, or September
5, 2006. He was involved in a motor vehicle accident. He was driving a Dodge
Dakota and he was struck 3 times. Since that time he has had the right knee pain,
cervical pain, and lumbar pain. Before the accident claimant never had any of these
problems. He has been undergoing therapy for the cervical spine and the lumbar
spine, which alleviated some of the discomfort for a very short amount of time and
then the pain returned. He states that the pain is mainly localized in the cervical and
lumbar spine and no involvement of the thoracic spine. The knee feels more
symptomatic on the medial portion of the knee than the lateral. It feels like a sharp,
stabbing sensation. There is some instability when he walks.
On inspection of the cervical spine, there was tenderness to palpation along the
spinous process and the paraspinal muscles. Claimant had increased pain with
lateral movement of his neck and also with flexion and extension of his neck. In
regards to the lumbar spine he has tenderness to palpation of the spinous process
and paraspinal muscles. He does not have any pain with palpation of the left or right
posterior superior iliac spine or along the trochanteric bursas. Claimant can flex and
extend and perform lateral movements and twisting exercises with the lumbar spine,
which causes some increased discomfort. In regards to the right knee he had
tenderness along the medial joint line. There was positive McMurray on the medial
portion of the knee.
Impressions:
1. Cervical pain.
2. Lumbar pain.
3. Right knee pain, clinical medial meniscal tear.
Dr. R K,
Date: 01/19/2007
Pre/postoperative Diagnoses:
Medial meniscus tear and osteoarthritis.
Lateral meniscus tear and chondral calcinosis, right knee.
Procedure Performed:
1. Arthroscopic partial medial and lateral meniscectomy, right knee.
6|Page
2. Chondroplasty, medial femoral condyle.
3. Chondroplasty, lateral femoral condyle.
4. Chondroplasty, patella.
5. Synovectomy "major", right knee.
G P, MD, Radiologist
Date: 11/17/06
MRI of the Lumbar Spine
Indications for study: Lumbar pain.
Impressions:
1. Multilevel bulging disco with facet joint arthritis leading to foraminal narrowing.
2. Probable hemangioma L2 vertebral body.
G P, MD, Radiologist
Date: 11/17/06
MRI of the cervical spine.
Findings: The vertebral bodies are normal in height and alignment. There are
spondylotic changes C4-5, C5-6, and C6-7 with narrowing of the disc spaces.
Impressions:
1. At C4-C5, right disco-osteophytic bulge with right foraminal stenosis rioted.
2. At C5-6 bulging disc with small right paracentral protrusion and mild bilateral
foraminal narrowing noted.
3. At C6-7, there is left-sided disco-osteophytic bulge with small left paracentral disc
protrusion and left foraminal stenosis.
V K, MD
03/03/2009
As per the transcripts of Dr. K, claimant was seen with a chief complaint of left hand
and left elbow. His left elbow has a large lump which is a fibrotic olecranon bursa.
When he bumps it hurts. He doesn't want to keep it any longer. He wonders if I can
take it off. In addition, he has a left ring finger that is terribly deformed at the distal
interphalangeal joint where it tilts off into varus. The whole dorsal aspect of the joint
is swollen and tense with obvious gouty tophi present. The x-rays confirm that there
is a large erosion of the bone. On the medial side of the distal end of the medial
phalanx there is a big erosion which is allowing this finger to diverge over in that
direction. It is quite painful.
Morton Hospital
Dr. W H
Date: 1/31/09
Test: Cervical Spine - Five Views Including Obliques.
Clinical Indication: Motor vehicle accident; neck pain.
Findings: Degenerative changes present at C5-C6 and C6-C7 with bilateral
foraminal encroachment at C5-C6 and foraminal encroachment on the left at C6-C7.
7|Page
Impression:
There was a transverse lucency at the base of the odontoid. While this was believed
to be artifactual, fracture in this region cannot be entirely excluded and CT of the
cervical spine is advised to exclude a fracture in this region.
Degenerative changes are present at C5-C6 and C6-C7 with bilateral foraminal
encroachment at C5-C6 and foraminal encroachment on the left at C6-C7.
Morton Hospital
Dr. G S
Test: left hand, three views
Clinical indication: Motor vehicle accident, hand pain.
FINDINGS: There were degenerative changes at multiple DIP and PIP joints and in
the carpal bones. In addition, there appeared to be some marginal erosive change in
the head of the fifth metacarpal and in the head of Hie fourth middle phalanx. While
these findings could be secondary to erosive osteoarthritis, gout should also be ruled
out although the location of these findings is somewhat unusual for gout.
Impression:
Degenerative arthritis.
Erosive changes which may be due to gout.
Morton Hospital
WH
Date: 1/31/09
Test: Lumbar Spine - Five Views Including Obliques
Clinical Indication: Motor vehicle accident.
There is a right convexity thoracolumbar scoliotic curve. Degenerative changes are
present from L3 through the sacrum. Intervertebral disk space narrowing with
associated osteophytes are present at L3-L4 and L4-L5. Vascular calcifications are
present.
Impression:
No acute bony abnormality is identified. Degenerative changes are present about the
spine.
Morton Hospital
GS
Test: Left wrist, three views
Clinical indication: Motor vehicle accident, left wrist pain.
FINDINGS: There is severe narrowing and sclerosis at the navicular, greater
multangular and multangular joints. There are extensive subchondral cysts in the
greater multangular and navicular bone. These findings are consistent with
degenerative arthritis.
Impression:
Degenerative arthritis.
HealthyVision
J P, DO
8|Page
Date: 06/17/08
Claimant was evaluated by Dr. P and following were the impressions:
1. Mild nuclear sclerotic cataracts OU.
2. Symptomatic posterior vitreous detachment OS with peripheral retinal
thinning without open breaks.
3. Mild hypertensive retinopathy OU.
4. Age related maculopathy OU.
Richey Surgery Center
Date: 01/22/2007
Transcripts of this facility list down the following procedures that claimant
underwent:
Procedures:
Knee arthroscopy, surgical; w/meniscectomy (medial and lateral, including meniscal
shaving);
Knee arthroscopy, surgical; major synovectomy, two/more compartments.
Primary Diagnosis: Primary localized osteoarthrosis, lower leg
Secondary Diagnoses
Disorder of calcium metabolism
Tear of medial cartilage/meniscus of knee, current
Tear of lateral cartilage/meniscus of knee, current
Essential hypertension, unspecified benign or malignant
Diagnostic Imaging Services
Dr. H M
Date: 10/20/08
Test: CT Scan Of The Head Without And With Contrast/Ct 3d Coronal Views:
Clinical history: Right eye visual problems.
Impression:
Mild cortical atrophy with no significant intracranial findings.
Mild bilateral chronic ethmoid sinus disease.
Diagnostic Imaging Services
Dr. H M
Date: 10/20/08
Test: CT Scan Of The Orbits With And Without Contrast/CT 3D Coronal Views:
Clinical History: Right eye visual problems.
IMPRESSION:
1. Unremarkable bilateral orbits. Recommend clinical correlation and further
evaluation with MRI Of the orbits for further evaluation if clinically warranted without
and with contrast.
2. Chronic sinus disease with a large left retention cyst of the maxillary sinus and
mild bilateral mucosal thickening of the ethmoid sinuses compatible with mild chronic
bilateral ethmoid sinus disease.
Spine and Rehab Medicine
9|Page
Dr. S K
Date: 11/10/2008
Date of MVA: 10/12/2008
Dr. K note dated 11/10/08 state that claimant was a restrained driver of a motor
vehicle that was involved in a car accident on October 12, 2008 at approximately
1:00 p.m. in Tarpon Springs, Florida. The claimant’s vehicle had stopped at a light
waiting for traffic to clear so as to make a turn when it was rear-ended. The force of
the impact pushed the patient's vehicle ahead through the intersection, made it cross
into the opposite lane, and then the patient's vehicle ended up hitting another motor
vehicle that was going straight in the opposite direction over its left rear part with the
patient's left front. The patient may have had a loss of consciousness for 2 to 3
minutes; he was dazed and disoriented and hurt all over. A couple of days later the
claimant was seen by Dr. R for a chiropractic evaluation and was then started on
adjustments and modalities. At present he is undergoing therapy 3 times per week.
Within 1 week the patient was seen by Dr. H, an ophthalmologist because of right
eye blurry vision and difficulty with depth perception and difficulty distinguishing red
color.
Claimant was complaining of neck pains which were graded at 8, associated with
occasional left hand numbness. He had upper back pains graded 8, low back pains
graded 10; these were localized. All these pains are constant. They are mostly dull in
nature. He reports having left wrist pains associated with tingling and numbness in
the fingertips. He does complain of dropping objects with the left hand. He did not
have this left hand problem prior to the accident. He complaints of having dull,
constant headaches, present mostly over the back of the head. He complains of
decreased balance since this motor vehicle accident.
On examination of neck, the claimant had reversal of cervical lordosis. On palpation,
tenderness was present over midline of the cervical spine with spasms over the
paraspinal muscles. Range of motion of neck: Forward flexion 50 degrees,
extension 30 degrees, right lateral flexion 15 degrees, left lateral flexion 20 degrees,
right rotation 30 degrees, left rotation 35 degrees. Muscle strength was 4+/5 in the
upper extremities. Sensation was decreased in the left hand fingertips with normal
reflexes. Axial compression and distraction test was positive.
On examination of back, there was tenderness present over midline of thoracic and
lumbar vertebrae with spasms over paravertebral muscles.
Examination of left wrist: Minimal tenderness noted over dorsal and volar aspects of
the left wrist. Median nerve compression test and Phalen's test was positive at the
left wrist.
Examination of head- Tenderness with spasms were palpable over occipitalis
muscles on the back of the head.
ASSESSMENT:
(1) Posttraumatic cervical spine sprain/strain.
(2) Posttraumatic thoracic spine sprain/strain.
(3) Posttraumatic lumbar spine sprain/strain.
(4) Myofascial pain syndrome involving cervical, thoracic, and lumbar paraspinal
muscles.
(5) Posttraumatic left wrist sprain with resultant carpal tunnel syndrome.
(6) Posttraumatic bilateral greater occipital neuralgia with headaches.
(7) Posttraumatic blurry vision with right eye.
10 | P a g e
Spine and Rehab Medicine
Dr. S K
Date: 11/10/2008
Electradiagnostic study of the left upper extremity was performed.
CONCLUSION: (1) Moderate to severe median nerve motor/sensory neuropathy
across the left wrist. (2) Mild to moderate ulnar nerve motor/sensory neuropathy
across the left wrist. (3) Mild to moderate ulnar nerve motor neuropathy across the
left elbow.
Chiropractic, Inc.
Date of Films: 10/15/2008
Type of Study: Davis series (APLC, APOM. Lateral Cervical, Flexion/extension and
Obliques)
Impressions:
1. Hypomobility in cervical flexion.
2. Mild to moderate DDD at C5 through C7.
3. Uncinate joint hypertrophy causing JVF encroachment of C5 through C7.
4. Subluxations noted from C2 through C7.
Chiropractic, Inc.
Date of Films: 10/15/2008
Type of Study: Lumbar series (AP lumbar, lateral lumbar, and oblique lumbar)
Impressions:
1. Calcification of the abdominal aorta with aneurysms.
2. Moderate facet degenerative joint disease at L5-S1.
3. Mild to moderate subluxation of L2, L4 and L5.
Dr. G P
MRI of the lumbar spine
Date: 11/17/06
Impression:
Multilevel bulging discs with facet joint arthritis leading to forarainal narrowing as
described above,
Probable hemangioma L2 vertebral body.
MRI of the lumbar spine:
Date: 11/17/06
FOR STUDY: Lumbar pain.
At L2-3, there is mild bulging disc slightly prominent left, lateral aspect leading to left
foraminal
narrowing.
At L3-4, a circumferential bulging disc noted with, facet joint arthritis leading to
bilateral foraminal narrowing.
At L4-5, also noted is a circumferential bulging disc with prominent broad-based
central disc bulge and bilateral foraminal stenosis with associated facet joint arthritis.
At L5-SI, a central disc bulge is noted. There is facet joint arthritis
11 | P a g e
Center for Bone and Joint Disease
Test: MRI of the right knee
Clinical History: Medial Meniscal tear
Impression:
1. There is a tear of the posterior horn of the medial meniscus. There are also
osteochondral defects on the medial tibial plateau and posterior medial
femoral condyle portion of the medial femoral condyle consistent with
osteochondral defects.
2. Irregularity and increased signal within the anterior cruciate ligament,
particularly along its upper posterior aspect suggesting a tear. There maybe
some bone edema near the tibial insertion.
Center for Reconstructive and Aesthetic Ophthalmology
Dr. S G
Date: 02/12/09
Dr. G in his letter to Dr. H has stated that claimant has been evaluated for optic
nerve problem and double vision. Claimant’s double vision is horizontal and greater
when he looks to the side. It was stated that claimant has monocular diplopia in the
right eye which is causing visual symptoms of significant nature, including reduction
in vision to 20/50 or worse.
12 | P a g e