(Month) (Date), (Year)
Company
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Re: Patient Name
Claim #: XXXXXXXXX-XXX-XXX
Date of Accident: MM/DD/YYYY
Date of IME: MM/DD/YYYY
Time In: 12:35 p.m.
Time Out: 1:10 p.m.
Date of Birth: MM/DD/YYYY
Dear Sir/Madam:
Thank you for referring (Patient Name) for an Independent Chiropractic Examination.
Records Reviewed:
1. 54 treatment notes from (XX) Center including dates of service from MM/DD/YYYY through MM/DD/YYYY. This included several exams that showed continued progression in both objective and subjective problems.
2. We reviewed a report from Dr. John Doe dated MM/DD/YYYY. Dr. Doe’s diagnoses were posttraumatic lumbar radiculopathy, posttraumatic right hip contusions, strain and sprain, rule out internal derangement, posttraumatic cervical sprain/strain, posttraumatic cervical and lumbar fibromyositis syndrome.
3. We reviewed 2 reports from Dr. Jane Doe. They were dated MM/DD/YYYY and MM/DD/YYYY. Dr. Jane Doe’s diagnoses were cervical facet syndrome, cervical disc herniation at 3 levels, cervical disc bulging, cervical radiculopathy clinical, posttraumatic lumbago, lumbar facet syndrome, lumbar disc bulging, clinical lumbar radiculopathy, myofascial pain syndrome, muscle spasm, sacroiliitis.
Dr. Jane Doe also had an EMG performed on MM/DD/YYYY that revealed right ulnar nerve conduction block across the elbow, right median sensory axonal and demyelinating neuropathy, left median sensory demyelinating neuropathy, and bilateral C5-6 radiculopathy. There were normal bilateral peroneal and tibial motor nerve conduction studies as well as normal bilateral sural and superficial peroneal sensory nerve conduction studies. There was no electric diagnostic evidence of a lumbar radiculopathy.
X-rays performed at (XX) on MM/DD/YYYY of the lumbar spine revealed pronounced disc space narrowing as well as the thoracic spine revealed diffuse multilevel disc narrowing. The cervical spine revealed malalignment with multilevel disc space narrowing, and the right hip revealed no evidence of fracture with the hip joints space appearing to be well maintained.
MRIs were performed at (XX) on MM/DD/YYYY of the cervical and lumbar spine and revealed malalignment with multilevel disc bulging/herniation at C5-6, C4-5, and C3-4. There was also disc bulging at C6-7 and C7-T1.
The lumbar MRI of MM/DD/YYYY performed at (XX) revealed disc bulging at L1-2, L2-3, L4-5, and L5-S1 with no herniations and multilevel degenerative changes.
History: (Patient Name) stated that he was the belted driver of a vehicle that made a turn and was hit on the front driver’s side by another vehicle. He did not hit his head or lose consciousness. He immediately felt neck pain and lower back pain. He went to Dr. (XX) who then referred him to the chiropractor, Dr. (YY). He has also seen Dr. Jane Doe and Dr. (ZZ). He sees Dr. Jane Doe regularly approximately once a month and continues to see Dr. (YY), the chiropractor, once a week at this time. He last saw the chiropractor on MM/DD/YYYY. He reports that he is being compliant with the treatment and that he has improved. He reports no new injuries.
Past History: His past medical history is remarkable for 5 or 6 accidents; although, he reports he was asymptomatic prior to this accident. He has had bilateral shoulder surgery as well as right knee surgery and right wrist surgery from various accidents. He states that prior to this accident though, he was performing his ADLs normally without any complications.
Employment History: (Patient Name) is employed by the (XX) as a (YY). He also works as a (ZZ). He has not missed any work as a result of this accident.
Present Complaints: Presently, he complains of right-sided neck pain graded 5/10 that comes and goes and occurs 3 to 4 days a week. He has good and bad days. He reports no headaches and no upper extremity symptoms. He reports no midthoracic symptoms. He has left lower back pain that is off and on with good and bad days once again and occurs approximately 3 days a week. He has no lower extremity pain or paresthesias. He used to walk 6 miles a day and is now only walking 2-3 miles a day. He also states that he has not swum since the accident. Overall, he reports that he is 50-60% improved.
IME Physical Examination: Examination disclosed a pleasant and cooperative (XX)-year-old male standing 5 feet 11 inches, weighing 222 pounds with no hair and black eyes. His pulse rate was 66 beats per minute.
Cervical Spine:
Cervical range of motion totaled 273/385 degrees with pain in all planes, right lateral flexion.
Cervical orthopedic testing revealed all cervical compression tests to be negative with a negative cervical distraction test.
Soto-Hall test was positive for cervicothoracic pain.
The right and left shoulder depression test were positive.
Palpation:
Palpation revealed mild bilateral suboccipital and cervicothoracic as well as midline cervicothoracic tenderness.
There was mild-to-moderate bilateral lumbar and bilateral sacroiliac tenderness.
There was mild bilateral suboccipital, right cervical, and bilateral lumbar paravertebral tenderness.
The left sacroiliac joint was restricted.
Neurological Examination:
Neurological examination revealed all upper and lower extremity DTRs including triceps, biceps, brachioradialis, patellar, and Achilles to be +2/5 equal and normal.
Dermatome sensations were tested with a Wartenberg pinwheel in the upper and lower extremities and were equal and normal.
Gross muscle strength was noted to be equal and normal in both the upper and lower extremities at +5/5.
Mannkopf’s test was positive on the right for pressure over the right upper dorsal area at 72 beats per minute, was borderline positive.
Disability Index:
The disability index was graded at 25-42% and severe.
Lumbar Spine:
The lumbar range of motion totaled 170/250 degrees with pain in all planes.
Right and left Kemp’s sign was positive for lumbar spine pain.
The right and left SLR was positive for posterior knee pain at 40 degrees with a positive Bragard’s test.
There was a negative right and left Patrick test.
The SLR appeared to be more of a right hamstring then a true sciatic neuralgia.
Derifield was positive on the right and there was a positive right and left Yeoman’s test.
Postural Analysis:
The postural analysis revealed a high left shoulder, high left ilium, and a decrease in the cervical lordosis.
Radiographic Review: The x-rays and MRI reports we reviewed were discussed earlier. The patient did bring with him the MRI CDs, but we were not able to open them on our computer.
IME Diagnoses: Based on (Patient Name’s) history, our review of the available medical information, and our examination findings, our diagnoses within reasonable medical certainty are as follows:
• Cervical, thoracic, and lumbosacral spine sprain/strain.
• C4-5, C5-6 disc herniation with a C6-7 disc bulge and a C7-T1 disc bulge.
• Multilevel lumbar disc bulges.
Causal Relationship: Provided (Patient Name’s) history is accurate, his injuries with the exception of the pre-existing degenerative changes are causally related to the motor vehicle accident on MM/DD/YYYY.
Discussion: At this time, on IME, he has shown significant improvement based on his statements as well as the exam findings of Dr. (YY). We are therefore recommending that he continue with chiropractic treatment once a week for 6 weeks, which should afford him ample opportunity to reach maximum improvement. Comorbidities in his case include the multiple disc herniations and disc bulges as well as the multiple previous surgeries and injuries. Nevertheless, he has shown significant improvement and continues to do so.
