Medical Summary

KARINA GARCIA

Medical Records Summary

DATE	BATES STAMP	PROVIDER	NOTE	COMMENT
04/18/06		Jose Saunders, D.C. Date of Incidence – 04/17/06	HISTORY OF PRESENT ILLNESS Miss Garcia presents for initial examination and evaluation of complaints arising from MVA (Motor Vehicle Accident) in which she was involved on 04/17/06. Patient stated that at 5:00 pm, she was the driver in a car which was slowing down while the other vehicle involved was travelling at approximately 46 mph. She stated that other vehicle struck her vehicle on left front side. Stated that road conditions were clean and dry and visibility was good. Damage to her car was considerable (totaled). Damage to other vehicle was mild. She did see the accident coming and thus was braced for impact. She was wearing seat belts and shoulder harness. Both driver's and front passenger's air bags deployed, but no side air bags. Car was equipped with headrests; her headrest was even with the top of her head at time of accident. She had her head facing straight forward at moment of impact. Her body struck the inside of vehicle on impact, air bags came in contact, and her knee hit the bottom of dash. No LOC (loss of consciousness) during the accident. Police showed up at the scene, and accident report was filled out. Following accident she was taken to the hospital emergency room. Patient did not have x-rays and lab work done. CHIEF COMPLAINT Initial complaints - Immediately following accident, patient reported fatigue, stiffness in lumbar region, soreness, headaches, pain in shoulder and neck region. Current Complaints - Constricting pain in neck. Pain radiates into head bilaterally, left shoulder and arms. Pain restricts her to perform daily activities. Symptoms aggravate by bending forward, backward, left, right, and by sitting. Aching and throbbing right frontal headaches. Symptom radiates into right side of neck, shoulder regions and arms. Difficulty in performing daily activities. Symptoms aggravate by sneezing, straining and by lifting heavy pounds. Aching and constricting pain in low back. Symptom radiate into shoulders and arms. Difficulty to carry out daily activities. Symptoms aggravated by bending forward, backward, twisting to left and right, sneezing, straining, standing, sitting and by lifting heavy pounds. Aching pain in mid back bilaterally. Difficulty to carry out daily activities. Symptoms gets aggravated by bending forward, backward, left, right, twisting to left, standing, sitting and by lifting heavy pounds. Aching and cramping pain in left shoulder. This radiates into left arm. This restricts her to perform her daily activities. It is aggravated by lifting heavy pounds. Aching and burning pain in both sides of jaw. Symptom radiates into both sides of neck and shoulders. Restricts to perform daily activities. Symptoms aggravated by straining and by chewing. Dull and aching pain in left knee. Restricts to perform daily activities. Symptoms get aggravated by standing and by walking. Activities of Daily Living - Reported suffering varying degrees of loss of functional capacity. Despite marked pain; showering; washing hair; washing face; brushing teeth; making bed; putting on shirt; putting on shoes; tying shoes; putting on her paints and taking out the trash can be done without much difficulty. Standing for long periods, sitting continuously, bending forward, backward, left and right, leaning forward and backwards can be managed alone, despite marked pain. Standing, sitting, reaching, walking for long periods, twisting to left and right, leaning to left and right and kneeling for long periods can be done, but not without some difficulty because of resulting pain. Pulling things while seated and pulling things while standing can be managed by herself, despite marked pain. Carrying large objects, climbing stairs, pushing things while seated and pushing things while standing can be done without much difficult, despite some pain; carrying small objects, carrying brief case and carrying large purses can be done without difficulty. Riding as passenger in a motor vehicle can be done without much difficulty, despite some pain. Ability to concentrate, read, and write and use computer or typewriter is slightly affected by her condition. Ability to take long and continuous sleep is restricted. PAST MEDICAL HISTORY Patient had prior chiropractic treatment. Couple of years back she had any pain which needed treatment. SOCIAL HISTORY Patient is a working in Missouri. Her boyfriend lives in New Jersey. She works at restaurant, 3-4 evenings per week, in 6-8 hour shifts. PHYSICAL EXAMINATION Patient right handed. ROM – restricted at cervical, thoracic and lumbosacral region. Jackson Compression test positive, Soto Hall test positive. Nachlas’ test, Gaenslen’ test, Hibb’s test and Yeoman’s test positive bilaterally. SLR and Kemp’s test positive bilaterally. Shoulder compression test, Ely’s heel to buttock test, Patrick’s test, Tredelenburg’s test positive bilaterally. The Abduction stress test and Adson’s Maneuver positive on right side. Foramina compression test and Pelvic rock test positive bilaterally with pain. RADIOLOGICAL EXAMINATION Cervical, thoracic and lumbar spine x-ray shows no fracture, gross osseous pathology or significant anomalies. ASSESSMENT Favorable results expected for this patient. TREATMENT PLAN Recommended home exercises, moist heat therapy, cervical traction, massage therapy, lumbar traction, spinal manipulation and trigger point therapy. Referred for neuromuscular re-education/massage, neuropsych. Will give physical therapy referral in future, after stabilization. Full spinal adjustments. Home P.T. WORK STATUS Work restrictions for the next four weeks. CAUSATION Based on assessment of patient's history, along with subjective complaints, objective findings, radiographic analyses, and test results, it is evident from a standpoint of medical certainly, that her current condition did result from the type of injury/onset described in this report.
04/20/06		Jose Saunders, D.C.	CHIEF COMPLAINT Neck pain 9/10, right frontal headache 8-10/10 today, mid back pain 7/10, low back pain 8-10/10, shoulder pain 7-9/10. Pain felt between 86% and all of the time she is awake. Symptoms having serious effect on her daily activities. knee pain 6-8/10; aggravates between 35% to 45% of time she is awake. Symptoms restrict her activities. Continued cervicalgia. Patient not very active due to certain amount of consistent pain. She is facing difficulty in sleeping. Prior to accident, no such symptoms were present or experienced. PHYSICAL EXAMINATION Restricted cervical, thoracic and lumbosacral ROM in all directions along with pain. Kemp’s test positive bilaterally, Tredelenburg’s test and Adson’s Maneuver positive. The Jackson Compression test, shoulder compression test, foraminal compression test positive. Positive hyperabduction test on right. SLR and Patrick’s test positive bilaterally. Soto Hall test positive with pain being localized at left side cervical rotation. Pelvic rock test positive bilaterally. Gaenslen’s test positive. Ely’s hip to buttock test, Hibb’s test Nachlas’ test and Yeoman’s test positive bilaterally. WORK STATUS Patient put on restrictions at work, half time and light duty. TREATMENT Home exercises, moist heat therapy, cervical traction, massage therapy, lumbar traction, spinal manipulation and trigger point therapy performed. Full spinal adjustment and home P.T. advised.
04/22/06		Jose Saunders, D.C.	CHIEF COMPLAINT Neck pain 8/10, headache 7-9/10 today, mid back pain 8/10, low back pain 7-10/10, shoulder pain 8-9/10, jaw pain 8/10. 76% of overall pain when awake. Symptoms aggravates while performing daily activities. Left knee pain 8/10; 35% to 45% of time when awake. Symptoms aggravates while performing daily activities. Patient very compliant and willing to do whatever it takes to recover. PHYSICAL EXAMINATION Same as on date 04/20/06. ASSESSMENT Minor improvement since last visit. TREATMENT Same as on date 04/20/06.
04/24/06		Jose Saunders, D.C.	CHIEF COMPLAINT Neck pain 9/10, headache 8-10/10 today, mid back pain 7/10, low back pain 8-10/10, shoulder pain 8-9/10, jaw pain 7-8/10. Overall 76% of pain when awake. Symptoms aggravates while performing daily activities. Knee pain 8/10; 25% to 50% when awake. Symptoms presently having some effect on her daily activities. Patient experiencing same problems. Some flare ups at cervical and lumbar regions today. She will visit as per schedule. Difficulty in sleeping. PHYSICAL EXAMINATION Same as on date 04/20/06.. ASSESSMENT Patient is in relief phase of care. TREATMENT Same as on date 04/20/06.
04/25/06		Jose Saunders, D.C.	CHIEF COMPLAINT Neck pain 8/10, headache 9-10/10 today, mid back pain 7/10, low back pain 7-10/10, shoulder pain 8-10/10, jaw pain 7-8/10. Overall 86% of pain when awake. Symptoms restricts to perform daily activities. Right knee pain 7-8/10; bothers 25% to 50% when awake. Symptoms restricts to perform daily activities. Patient reported cervical, thoracic and lumbar pain and headache. Cephalgia is primarily occipital and temporal. Describes cephalgia as different than any other headache she had before. Lot of shooting pain. TMJ continues to hurt bilaterally. Difficulty sleeping. All over soreness and body muscle stiffness. PHYSICAL EXAMINATION Same as on date 04/20/06. Brachial lacerations healing nicely. ASSESSMENT Patient is in relief phase of care. TREATMENT Same as on date 04/20/06.
04/27/06		Jose Saunders, D.C.	CHIEF COMPLAINT Neck pain 8-10/10, headache 9-10/10, mid back pain 7/10, low back pain 8-10/10, shoulder pain 8-10/10, jaw pain 7-8/10. Overall 76% of pain when awake. Symptoms restricts to perform daily activities. Right knee pain 7-8/10; bothers 35% to 40% when awake. Symptoms presently having some effect on her daily activities. Patient is very careful with her movements at home and work. PHYSICAL EXAMINATION Same as on date 04/20/06. Muscle tension remains. ASSESSMENT Patient is in relief phase of care. TREATMENT PLAN Home exercises, moist heat therapy, cervical traction, massage therapy, lumbar traction, spinal manipulation and trigger point therapy performed. Full spinal adjustment and home P.T. advised. Referred to TMJ specialist. Suspected TMJ syndrome post trauma and possibly contributing to cephalgia. Patient given permission to walk gently and carefully 5-10 minutes every other day.
05/02/06		Jose Saunders, D.C.	CHIEF COMPLAINT Neck pain 8-10/10, headache 9-10/10, mid back pain 8/10, low back pain 8-10/10, shoulder pain 8-10/10, jaw pain 7-8/10. Overall 66% of pain when awake. Symptoms having serious effect on her daily activities. Right knee pain 6-8/10; bothers 35% to 60% when awake. Symptoms presently having some effect on her daily activities. Throbbing pain in lumbar spine. Thoracic stiffness and ache. This is exacerbating some of her symptoms greatly. PHYSICAL EXAMINATION Restricted cervical, thoracic and lumbar range of motion in all directions with pain. Improvement in Range of motion for about 24-48 hours after adjustment.. Rest same as on date 04/20/06. ASSESSMENT Patient has experienced some improvement. TREATMENT Home exercises, moist heat therapy, cervical traction, massage therapy, lumbar traction, spinal manipulation and trigger point therapy performed. WORK STATUS Instructed to restrict work. Patient agreed.
05/06/06		Jose Saunders, D.C.	CHIEF COMPLAINT Neck pain 8/10, headache 7-10/10, mid back pain 8/10, low back pain 7-10/10, shoulder pain 8-10/10, jaw pain 7-8/10. Overall 86% pain when awake. Symptoms having serious effect on her daily activities. Right knee pain 6-8/10; bothers 25% to 50% when awake. Symptoms presently having some effect on her daily activities. Cephalgia at right temporal. Patient is stretching. Spoke at length about strengthening neck musculature, but, her spinal column and the edema surrounding is too volatile at this time. PHYSICAL EXAMINATION Improvement in ROM at cervical, thoracic and lumbar regions after adjustment, then ADLs continue to affect all areas. Kemp’s test positive, Tredelenburg’s test and Adson’s Maneuver positive on right side. The Jackson Compression test, shoulder compression test, foraminal compression test positive. Positive hyperabduction test on right. SLR and Patrick’s test positive bilaterally. Soto Hall test positive with pain being localized at cervical rotation. Pelvic rock test positive bilaterally. Gaenslen’s test positive. Ely’s hip to buttock test, Hibb’s test Nachlas’ test and Yeoman’s test positive bilaterally. ASSESSMENT Patient has experienced minor improvement since last visit. TREATMENT Home exercises, moist heat therapy, cervical traction, massage therapy, lumbar traction, spinal manipulation and trigger point therapy performed. Full spinal adjustment.