(Month) (Date), (Year)
Company
Address Line 1
Address Line 2
Re: (Patient Name)
Claim#: XXXXXXXXXXXX
Date of Birth: MM/DD/YYYY
Date of Accident: MM/DD/YYYY
Date of IME Examination: MM/DD/YYYY
Time In: 6:15 p.m.
Time Out: 6:45 p.m.
Dear Sir/Madam:
Thank you for referring this patient for IME, Independent Chiropractic Examination.
Records Reviewed:
1. Three treatment notes from (XX) Center including 41 treatment notes from MM/DD/YYYY through MM/DD/YYYY. This included several examinations dated MM/DD/YYYY through to MM/DD/YYYY, MM/DD/YYYY and MM/DD/YYYY that showed progressive improvement in the patient’s condition.
2. A report from Dr. (XX), a neurologist, dated MM/DD/YYYY, with impression of lumbar radiculopathy, cervical sprain, cervical displacement of disc. There was an MRI study reviewed that indicated that the patient had cervical disc herniations at C3-4, C4-5 and C5-6.
3. There are x-rays reports from (XX), which the patient also brought with her. These included x-rays of the lumbar spine, cervical spine, and thoracic spine dated MM/DD/YYYY that showed some narrowing at L5-S1 as well as some rotation malpositions at multiple levels. There were noted some multilevel disc space narrowing in the lower levels of the thoracic spine. We reviewed these x-rays films and our findings were consistent with these reports.
4. We also reviewed a cervical and lumbar MRI performed at (XX) on MM/DD/YYYY that revealed multiple cervical disc herniations and protrusions from C4 through C7 and a L5-S1 disc protrusion/bulge.
History: (Patient Name) stated that she was the driver of a vehicle that T-boned another car that ran a stop sign. After hitting the car, she also ran into a gate. There was airbag deployment. She immediately felt some head and chest pain, and since she lived close to the accident, her husband drove over, picked her up and took her to (XX) Hospital where she was treated and discharged.
She then followed up with (XX) Spine and Rehab Center and has seen Dr. (XX) once. She continues to go to the chiropractors at (XX) Spine and Rehab Center twice weekly and last saw the chiropractor on the morning of this examination.
Overall, she states that she is doing better and she feels very good the day she goes to the chiropractor. Overall, she reports that she is approximately 25% improved. She reports that she does take ibuprofen 600 mg, especially to help her sleep. She also reports that she continued to work and that the work does tend to aggravate her condition.
Past History: (Patient Name) reports a motor vehicle accident 13 years ago where she hit a jitney in the snowstorm and there were no injuries. She reports no previous neck or back pain.
Employment History: She is employed as a hostess at (XX). She did not miss any work as a result of this accident. At the time of the accident, she was on vacation and has not missed any time once she returned from vacation.
Present Complaints: Presently, she complains of neck pain that is bilateral and is present 50-75% of the time, graded 6-8/10. She reports no recent headaches; although, she states that she had headaches for several days after the accident after the airbag hit her in the head.
She reports no upper extremity symptoms. She reports no midthoracic pain. She reports bilateral left greater than right lower back pain, graded 8-9/10, that is constant and worse with yard work or work. She is better with rest. She states that she can no longer sleep on her side, which is her normal position and has to sleep on her back, which has sleeping difficulty.
She also has left leg pain and that is both posterior and is in the back of the leg greater than the front of the leg with tingling. This pain is all above her knee and is graded 5-8/10. It comes and goes during the day and is present 50-75% of the day. She reports no right lower extremity symptoms.
IME Examination: Examination disclosed a pleasant and cooperative (XX)-year-old female standing 5 feet 7 inches, weighing 168 pounds with brown hair and brown eyes. Pulse rate was 80 beats per minute.
Cervical Spine:
Cervical range of motion totaled 303/385 degrees with pain in all planes in the left cervical spine. She had a positive right and left Jackson’s cervical compression test with negative neutral cervical compression test.
She had a positive right/left shoulder depression test and Soto-Hall test was positive for cervical and thoracic pain.
Palpation revealed mild left suboccipital bilateral cervical and bilateral cervical and thoracic tenderness with mild bilateral cervical thoracic paravertebral spasm.
There is moderate bilateral lumbar and midline lumbar as well as bilateral sacroiliac tenderness and mild to moderate bilateral lumbar and lumbosacral paravertebral spasms.
Neurological Examination:
The neurological examination revealed the upper and lower extremities DTRs including biceps, triceps, brachioradialis, patellar and Achilles +2/5 equal and normal.
Sensory examination using Wartenberg pinwheel revealed significant hypoesthesia and almost numbness of the entire left upper and left lower extremities.
Gross muscle strength testing in the upper and lower extremities was equal and normal at +5/5.
Mannkopf’s test was positive with an increased pulse rate of 100 beats per minute with compression of the left lumbosacral area indicating that the patient was not malingering.
Disability Index:
The disability index was graded at 80% and crippling.
Bilateral Shoulder Examination:
Bilateral shoulder examination was within normal limits.
Lumbar Spine:
Lumbar range of motion totaled 195/250 degrees with pain in all planes.
There was a positive left and right Kemp’s sign.
The right sacroiliac joint was restricted on posterior glide.
The left SLR was positive at 45 degrees for low back pain with a positive Bragard’s test.
The right SLR was positive at 70 degrees for low back pain with a negative Bragard’s test.
Fabere/Patrick test was negative bilaterally.
There was positive right Derifield, and there was a positive bilateral Yeoman’s and Nachlas test.
Postural Analysis:
There was a high right ilium and right left shoulder with a left head tilt.
There was a decrease in the cervical lordosis.
Radiographic Review: The films and reports of x-rays and MRIs that we reviewed were discussed earlier.
Diagnoses: Based on (Patient Name’s) history as well as our review of the available medical information and our examination findings, our diagnoses within reasonable medical certainty are as follows:
1. Cervical, thoracic and lumbosacral spine sprain/strain.
2. Headaches, resolved.
3. Multiple levels of cervical disc protrusion and a lumbar disc protrusion at L5-S1.
Causal Relationship: Provided (Patient Name’s) history is accurate, her injuries are causally related to the motor vehicle accident on MM/DD/YYYY.
Discussion: At this time, the records provided by (XX) coupled with the verbal history of (Patient Name) as stated indicates that she is improving. She has continued to work through her injury as a hostess on her feet for several hours at a time, which appears to have slowed her progress.
Nevertheless, we are recommending continued chiropractic care twice a week for 6 weeks at which time a second IME should performed to assess whether she has reached maximum medical improvement or not. Presently, she does not require household help, and there is no medical necessity for either massage therapy or physical therapy. Her prognosis is good and she does not appear to need any additional medical supplies. At this time, there does not appear to be any need for surgery but that is beyond our scope.
