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Clinical Notes & Documentation
April 22, 2004
Gary R. Stone
Dear Mr. Stone,
Susan Martin first came to this office on February 5, 2004 seeking treatment for injuries which were sustained during a motor vehicle accident which occurred on February 1, 2004. Mrs. Martin is a female who was born on 6/8/63.
DESCRIPTION OF INJURY/ONSET
On the initial visit, Susan reported the following symptoms:
Mrs. Martin relates that at the time of the accident she was the driver of a vehicle which she describes as a compact car which was stopped. Susan stated that the other vehicle involved in the primary impact of the accident is best described as a full size truck. During the accident the vehicle that Mrs. Martin was in was struck squarely from behind by the other vehicle involved in the primary impact of the accident.
At the time of the accident Mrs. Martin states that she was not wearing her seat belt and was not wearing her shoulder harness. The airbag in Mrs. Martin's vehicle did not deploy. Susan indicates that she was not anticipating the impact and was not braced. At the point of the impact she was looking straight ahead. Mrs. Martin does not believe she lost consciousness due to the trauma of the accident.
After the history was taken, the following exams were performed: General Exam on 2/5/97, Cervical Exam on 2/5/97.
The following radiographs were ordered and evaluated to assist in arriving at a differential diagnosis and treatment plan: APOM, APLC, LCN, LCF, and LCE.
PHYSICAL EXAM FINDINGS
Susan's weight was reported to be about 112 pounds. Her height was reported to be about 61 inches. Susan's pulse rate was measured at 70 beats a minute. Susan's temperature was measured and found to be 97.8 degrees. Blood pressure of the right arm was taken while Susan was seated and found to be 120/70 millimeters of Mercury.
INITIAL EXAM FINDINGS
Significant findings from the first examination(s) include:
INITIAL RANGE OF MOTION FINDINGS
ROM findings from the first examination(s) include:
First Cervical ROM - February 5, 2004
Based upon the history, symptoms and objective findings, the following initial diagnosis was rendered on February 5, 2004:
PRIMARY, Acute, and Moderate Migraine 346.9
The health history indicates that the condition which Mrs. Martin presented with is a new condition.
Based upon a review of the mechanism of injury and the information contained in the literature which relates to these conditions I can say with a reasonable degree of certainty that the conditions identified are the direct result of the trauma sustained in the accident. The accident occurred on February 1, 2004.
In order to address the conditions identified, the following procedures were provided to Mrs. Martin under the initial treatment plan which was established on February 5, 2004:
- Activator Adjustments
The following limitations were established as part of that treatment plan to avoid exacerbation of Mrs. Martin's condition:
- Work must be limited to 8 hours or less a day
Mrs. Martin was scheduled to be seen at a rate of approximately 2 to 3 times a week. This frequency of care was designed to continue for 4 to 5 weeks. This treatment plan includes an examination at the end of the scheduled care to re-evaluate Mrs. Martin's condition and evaluate her progress.
Mrs. Martin's progress was monitored by performing the following examinations: Cervical Exam on 4/5/97.
MOST RECENT EXAM FINDINGS
Significant findings from the most recent examination(s) include:
MOST RECENT RANGE OF MOTION FINDINGS
ROM findings from the most recent examination(s) include:
Most Recent Cervical ROM - April 5, 2004
ACTIVITIES OF DAILY LIVING ASSESSMENT
On February 6, 2004, the patient completed a Neck Pain Disability Index Questionnaire. This subjective test measures the degree of functional impairment of individuals with neck pain. Susan scored a 46%, or moderate disability in the ability to perform the normal activities of daily living. A final Neck Pain Disability Index Questionnaire was completed by Susan on April 5, 2004 and she scored a 20%, or mild disability.
The progress that Mrs. Martin made during the course of treatment was uncomplicated.
A review of the examinations shows significant increase in the cervical range of motion.
The final review of examinations shows that over the course of treatment there was a marked reduction in positive orthopedic findings, palpable edema, palpable myospasm, and tenderness.
In her current condition Mrs. Martin should avoid having her head tilted backward for any length of time and sleeping on her stomach.
Mrs. Martin can anticipate periodic flare-ups of symptoms due to normal activities associated with daily living. The periodic flare-ups will likely require some level of chiropractic intervention.
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