Jenifer Del Mundo

Greater Buffalo Accident & Injury Chiropractic Medical Building 1275 Main Street, Suite 110 Buffalo, NY P- F- FACSIMILE COVER SHEET Please deliver immediately TO: FROM: RE: DATE SENT: 08/10/2018 Greater Buffalo Accident & Injury Chiropractic, PC Adjunct Associate Professor - Family Practice, SUNY Buffalo School of Medicine and Biomedical Sciences Graduate - Royal College of Physicians - Certified Physician Educator - 2017 Clinical Director - Fellowship Spinal Biomechanics and Trauma Adjunct Post Graduate Faculty, Cleveland Chiropractic University Adjunct Clinical Assistant Professor, Texas Chiropractic College William J Owens Jr, DC, DAAMLP Medical Building 1275 Main Street Suite 110 Buffalo, NY 14201 P - F - Re: Date of Birth: Examination Date: Diagnosis ICD - 10 Diagnosis: M50.20Other cervical disc displacement, unsp cervical region S13.4XXASprain of ligaments of cervical spine, initial encounter M53.1Cervicobrachial syndrome S14.2XXAInjury of nerve root of cervical spine, initial encounter S34.21XAInjury of nerve root of lumbar spine, initial encounter S24.2XXAInjury of nerve root of thoracic spine, initial encounter M54.5Low back pain M54.6Pain in thoracic spine M62.40Contracture of muscle, unspecified site S06.0X0AConcussion without loss of consciousness, initial encounter S22.22XAFracture of body of sternum, init encntr for closed fracture F51.12Insufficient sleep syndrome These diagnosis were evidenced by the patient’s history, physical examination findings, range of motion testing and review of available diagnostic studies. Care Plan Three visits per week is warranted for six weeks with re-evaluation in six weeks. To increase functional mobility and correct segmental biomechanical abnormalities, the cervical spine, thoracic spinal region, lumbar spinal region, left SI joint, and right SI joint received adjustment. Heat therapy was administered to the cervical area, thoracic region, and lumbar region. This treatment is given to increase local circulation. To decrease vertebral fixation and muscle spasm, the cervical spine, thoracic spinal region, and area of the low back received traction done manually. Treatment consisted of range of motion exercise to the cervical area, and lumbar spine, in order to increase the functional range motion. Goals of treatment are to decrease pain, increase ROM, improve gait and reduce trigger points. Medical Management and Referral Based on the patient’s current findings I am referring the patient for an orthopedic surgical consultation for a second opinion regarding their spinal injury. I have discussed the clinical reasoning for the referral and the patient understood that it is medically necessary and co-management is appropriate given their current condition. I am referring the patient for imaging of the cervical spine. The purpose of this referral is to evaluate the integrity of the vertebrae and adjacent structures of the cervical spine. The study will be reviewed with the patient once the results are obtained. I am referring the patient for imaging of the thoracic spine for the purpose of evaluating the health and integrity of the vertebrae and the adjacent anatomical structures. The actual study and the results of the imaging will be reviewed with the patient once the results are obtained. Lumbar spine imaging is being ordered. This referral is being made in order to evaluate the integrity of the patient’s vertebrae and the adjacent anatomical structures. When the results of this study are obtained, they will be reviewed with the patient, as well as the actual study. I am referring the patient for imaging of the cervical spine top evaluates the health and integrity of the vertebrae and adjacent anatomical structures. The MRI was ordered to rule out a space occupying lesion of the spinal canal or foramen to determine if a surgical consultation is required. I will review the actual study with the patient once the results are obtained. I am referring the patient for imaging of the thoracic spine to evaluate the health and integrity of the vertebrae and adjacent anatomical structures. The MRI was ordered to rule out a space occupying lesion of the spinal canal or foramen to determine if a surgical consultation is required. I will review the actual study with the patient once the results are obtained. I am referring the patient for imaging of the lumbar spine to evaluate the health and integrity of the vertebrae and adjacent anatomical structures. The MRI was ordered to rule out a space occupying lesion of the spinal canal or foramen to determine if a surgical consultation is required. I will review the actual study with the patient once the results are obtained. Based on the historical and physical examination evidence of a non-displaced fracture and the plain film radiographs not being conclusive. I am referring the patient for a Bone Scan to evaluate sternum fracture. This test is required in order to render an accurate diagnosis and is necessary before initiating any aggressive chiropractic intervention. Assessment M is determined to be at an overall status of acute pain from trauma. The patient’s response to treatment is undetermined until further assessment. These are multiple injuries to separate regions of the patient’s spine. These regions are different body parts and may respond at different rates. I have discussed the possibility of one region responding differently, or more slowly because they are separate injuries, with the patient and they understand that the different regions may have a different response to care. Chiropractic management of alterations in spinal biomechanics and its surrounding supporting structures is the primary focus of our practice. We will update you on any changes that occur in regards to changes in the patient’s diagnosis, response to care, or any increase in their active therapy. Based on the patient’s history, examination findings and my assessment, imaging is clinically warranted and medically necessary to determine a proper prognosis, diagnosis and treatment plan. The examination findings objectively confirm my diagnosis and clinically correlate with the patient’s subjective complaints. Chiropractic care is therefore medically necessary. Medical Necessity Evidence Because of the above stated accident, the patient has suffered multiple injuries. In a recent research study, the authors confirmed this observation to a greater degree. Hincapié, Cassidy, Côté, Carroll, and Guzmán (2010) submitted in research paper to the World Congress on Neck Pain. The authors state, “The vast majority of persons involved in MVCs have neck pain, however, this is but one area of pain localization that most commonly involves multiple areas of the body” (Hincapié et al., 2010, p. 438). They went on to describe the details of the results as “Pain confined to a single body area was very rare. Just 0.4% of respondents (28 of 6481) reported pain that was confined to the posterior neck area alone (Hincapié et al., 2010, p. 436). In their final results, the authors show that 86.2% of respondents reported posterior neck pain, 75% had posterior shoulder pain, 72% reported head pain, 66% had mid-back pain, and 60% reported lumbar pain. Hincapié, C. A., Cassidy, J. D., Côté, P., Carroll. L. J., & Guzmán, J. (2010). Whiplash injury is more than neck pain: A population-based study of pain localization after traffic injury. Journal of Occupational and Environmental Medicine, 52(4), 434-440. Patient History The patient states on 7/11/18 she was the seat-belted front seat passenger of a vehicle driving straight when another vehicle making a turn stuck the vehicle she was in on the front passenger side. She states at the time of impact she was shoved sideways and whipped backwards within the vehicle causing her head to ride over the head rest, her body to strike the side door and the lap belt to pull across her body. She recalls immediately following the accident she was dazed and experienced pain in her neck, chest, back, stomach, pelvis, right arm, low back and chest. She states that she went to the hospital 6 days after the accident where she was examined and x-rays and a CT were taken. She reports a past history of neck pain. She presents today for evaluation of her condition. Subjective Complaints The patient entered the office today and said that she is experiencing constant headache pain bilaterally. She related that there is pain experience in the left and right neck area. She further reported that she has been suffering pain in the region of the right shoulder. Additionally, she stated that she’s been having pain in the right elbow area. M also stated that she has pain in the right wrist area and that she has been suffering right hand pain. She says she has experienced numb sensations radiating to the right index finger, right second finger, right third finger and right little finger. The patient states that she has pain bilaterally in the upper back area, finally related she is experiencing pain bilaterally in the area of the lumbar spine continued to describe that she noticed pain radiating to the right hip, right popliteal region, lateral right foot and right gluteal area and that she has developed tendon inflammation in the hip on the right. She reports shortness of breath and states that coughing increases her pain. When asked to rate her pain on a scale of 1 to 10 she rates her neck pain at 7, mid back pain at 10 and low back pain at 6. The following evidence and symptoms TBI = Traumatic Brain Injury, MTBI = Mild Traumatic Brain Injury and PTSD - Post Traumatic Stress Disorder are present in the patient’s history, have persisted since the accident and clinically correlate with the mechanism of injury. Nausea: persistent Vomiting Amnesia Irritability Lethargy Cognitive Changes Vision Blurred Loss of Consciousness Headache Migraine Personality Changes Difficult Walking Deviated Eye Movement Ringing in the Ears: bilateral, persistent Light Sensitivity Loss of Balance and Coordination: persistent Occupation None Work Status Not Working MEDICAL HISTORY AND REVIEW OF SYSTEMS Past Medical History Neuropathy Past Surgical History None reported Review of Systems Denies any fever or chills, negative for any change in skin, head and neck, immune, cardiac, respiratory, digestive, urinary, hepatic, renal or psychiatric issues at this time. Allergies None reported Medications Neurontin Duxdotion Lortab as needed Social History Alcohol: 2-4 drinks per week reported Tobacco: denied Family History Parkinson’s: brother PHYSICAL EXAMINATION Vitals: Ht: 5”2”BP: 128/80 mmHg Wt: 130lbsPulse: 72bpm Right handed Cardiovascular: Peripheral pulses are 2+ and equal in the bilateral upper and lower extremities. Capillary refill brisk and less than 2 seconds. Musculoskeletal: Spinal evaluation for functional range of motion revealed a very significant degree of joint restriction at C1-C3, C5-T2, T4-T5, T11-L5 and the left ilium, and a moderate location of the spinal joints at T6, T8-T10 and the right ilium. A severe intensity of pain at the right ilium on the right, and C1 to C4, C7 to T2, T4 to T12, and L2 to L5 bilaterally and a fairly moderate amount of pain at the left ilium on the left was indicated on palpation examination of the spinal tissues. Moderate trigger points were found on the right in the cervical, thoracic and lumbar spine. Orthopedic Testing on the Cervical Spine revealed: NAME: Cervical Compression……………………..POSITIVE RIGHT PERFORM TEST: With the patient seated and with the head and neck in the neutral position, the doctor compresses the cervical spine axially with pressure on the top of the head. POSITIVE: Increase in local or radiating pain INDICATION: Disc herniation NAME: Distraction……………………………………..POSITIVE PERFORM TEST: The patient will be seated as the doctor rotates the patient’s head to point of pain, then distracts, (if the patient has pain in the Neutral position, the head should be distracted in the Neutral position.) POSITIVE: Decrease in Radiating Arm Pain. INDICATION: Nerve Root Encroachment. NAME: Jackson’s Compression……………………..POSITIVE RIGHT PERFORM TEST: As the patient is seated laterally flex the head to the affected side & then axially compress. POSITIVE: Increased in Radiating ARM Pain. INDICATION: Nerve root Encroachment. NAME: Shoulder Depression…………………………..POSITIVE BILATERALLY PERFORM TEST: As the patient lies supine or seated the doctor laterally flexes the patient’s head away from affected side while compressing patient’s shoulder to point of pain. Then rotate head away. POSITIVE: Reproduction of Radicular Arm Pain upon lateral flexion, then exacerbation of that pain upon rotation. INDICATION: ADHESIONS OF THE DURAL SLEEVE OR NERVE ROOTS. NAME: Soto-Hal……………………………………..POSITIVE PERFORM TEST: As the patient lies supine, the doctor stabilizes over patient’s sternum. Doctor then flexes patient’s head & neck onto his chest. POSITIVE INDICATION: Pain helps to localizer either: A.Anterior Spinal Compression injuries or B.Posterior Spinal Stretching injuries NAME: Upper Limb Tension Test of Elvey…………………….POSITIVE RIGHT PERFORM TEST: Position 1: Arms abducted to 90° with elbows extended. Position 2: Dorsiflex wrists. Position 3: Tilt head to side, ear to shoulder. Each maneuver progressively increases stretch on the brachial plexus. * This is equivalent to the Straight Leg Raise in the lower extremity. Orthopedic Testing of the Hip revealed: NAME: Patrick FABERE (aka The Sign of FOUR) ________ POSITIVE RIGHT PERFORM TEST: As the patient is lying supine, place the heel of the AFFECTED leg or over the opposite knee so that the affect leg is in the following position: Flexion (knee) Abduction (Hip) External Rotation (Hip) Extension (Hip) Apply pressure on the affected knee downward (toward the table). POSITIVE: Pain in the Hip INDICATION: Anterior Hip Joint Lesion. NAME: Gaenslen’s …………………………POSITIVE RIGHT Orthopedic Testing of the Shoulder revealed: NAME: Apley’s Scratch Test ………………………….POSITIVE RIGHT PERFORM TEST: Have the patient perform the following maneuvers actively: 1. Internally rotate & adduct anterior to chest. 2. Internally rotate & adduct in back. 3. Externally rotate & abduct. POSITIVE: The ROM’s should be Symmetrical from side to side (& within normal limits compared to others). INDICATIONS: A. Adhesive Capsulitis B. Shoulder Pathology (if Decreased ROM is due to pain) NAME: Impingement Test ……………………………………..POSITIVE RIGHT Orthopedic Testing of the Lumbar Spine revealed: NAME: Lasegue …………………...POSITIVE at 10 DEGREES on the RIGHT PERFORM TEST: The patient lies supine then does a SLR on affected area. POSITIVE: Lower back and sciatic pain. NAME: Kemp’s ………………………………………………………...POSITIVE RIGHT PERFORM TEST: The patient can stand or sit while anchoring the pelvis with one hand and from the shoulder, pull the patient into extension, lateral flexion and ipsilateral rotation. POSITIVE: Radiating leg pain. [NOTE: Lower back pain indicated Facet Imbrication, but is NOT considered to be a positive finding.] INDICATION: A. Pain to the ipsilateral leg when laterally flexing toward that side indicates a Lateral Disc. B. Pain to the contralateral leg when laterally flexing away from that side indicated a Medial Disc. NAME: Yeoman……………………………...POSITIVELY BILATERALLY PERFORM TEST: As the patient lies prone, exert pressure downward over the affected SI with one hand while flexing knee and hyper extending the hip. POSITIVE: Pain Deep in the SI Joint. INDICATION: Sprain of the anterior SI Ligaments. NAME: Braggard…………………………………………..POSITIVE RIGHT PERFORM TEST: The patient does a SLR to the point of pain, then dorsiflexes. POSITIVE: An increase in radicular pain with the dorsiflexion. Neurological Testing revealed: The patient was oriented to person, place and time. There was no evidence of speech pathology. No ataxia or drift was noted. Muscle testing in the upper extremity was within normal limits bilaterally and all myotomes were graded +5/5 bilaterally. Hoffman’s sign was negative. Deep tendon reflexes were present and equal bilaterally being rates as +2/5, with the exception of left triceps which was absent. There was no evidence of clonus. Decreased sensation was found over right C6, C7 and T1 dermatomes. Muscle testing in the lower extremity was within normal limits bilaterally and all myotomes were graded +5/5 bilaterally. Plantar response was down going bilaterally. Deep tendon reflexes were present and equal bilaterally being rates as +2/5. There was no evidence of clonus. Nerve root tension signs were found at L4, L5 and S1 on the right. While palpating the patient I have observed multiple myofascial trigger points over the injured area which are contributing to the pain associated with the above stated condition. The patient is experiencing muscle spasm as outlined above. This is a direct result of their condition and a focus of therapeutic intervention. Muscle spasm is a source of pain and restrictions in motion. These findings correlate clinically with the patient’s complaints and their range of motion restrictions both segmentally and regionally. Brain function following a motor vehicle accident can be altered in what is called a TBI (traumatic brain injury), MTBI (mild traumatic brain injury) or concussion. In order for these to occur, however, there has to be shearing of the axons in the brain which are the long connecting arms of the neurons. When these get “overstretched.” there is impairment to how information is processed. In a study published in 2006 in the Canadian Journal of Neuroscience, the authors stated, “We sought to determine whether the mechanical forces of whiplash injury or concussion alter normal processing of middle-latency SEPs” (Zumsteg, Wennberg, Gutling, & Hess, 2006, p. 379). They discovered, “The SEP findings of our prospective study provide objective evidence that whiplash and concussion involve reversible pathophysiological changes affecting the same brain areas, providing support for the hypothesis that the overlapping clinical symptomatology post whiplash and concussion may reflect a similar underlying mechanism of rotational mild traumatic brain injury” (Zumsteg et al., 2006, p.384). The authors demonstrated that a portion of the studied population did continue on with long-term symptoms. It is, therefore, critical to have trauma patients tested early when appropriate. They concluded, “At the very least, however, the ability to record an objective physiological marker common to whiplash and concussion may form the basis for future investigations into the mechanisms underlying mild traumatic brain injury” (Zumsteg et al., 2006, p. 384-385). Reference Zumsteg, D., Wennberg, R., Gutling, E., & Hess, K. (2006), Whiplash and concussion: Similar acute changes in the middle-latency SEPs. Canadian Journal of Neurological Sciences, 33(4), 379-386. Copyright © 2009 ---. All Rights Reserved. Vertebro-Basilar Assessment Maignes Sign: negative Barre-Lieou Sign: negative Deklyne Test: negative Cervical Quadrant: negative During the examination, there was a visual restriction in the patient’s range of motion. I ordered a specific range of motion test to further evaluation the range of motion deficits. All ranges of motion are based on the American Medical Association’s guide to the Evaluation of Permanent Impairment, 5th and were performed by dual inclinometers. Normal (Degree)Patient(Degree) CERVICAL ROM: Flexion5018= 64% deficit Severe pain Extension6020= 67% deficit Severe pain Right Lateral Flexion4518= 60% deficit Severe pain Left Lateral Flexion4520= 56% deficit Severe pain Right Rotation8062= 23% deficit Severe pain Left Rotation8060= 25% deficit Severe pain Normal (Degree)Patient (Degree) THORACIC SPINE Flexion6010= 83% deficit Severe pain Right Rotation3012= 60% deficit Severe pain Left Rotation 3018= 40% deficit Severe pain Normal (Degree)Patient (Degree) LUMBAR ROM: Flexion6010= 83% deficit Severe pain True Lumbar Extension258= 68% deficit Severe pain Right Lateral Flexion 258 = 68% deficit Severe pain Left Lateral Flexion258 = 68% deficit Severe pain Normal (Degree)Patient (Degree) RIGHT SHOULDER: Flexion18080= 56% deficit Extension5020= 60% deficit Abduction180100 = 44% deficit Adduction5020= 60% deficit Internal Rotation9060= 33% deficit External Rotation9032= 64% deficit LEFT SHOULDER: Flexion180Normal Extension50Normal Abduction180Normal Adduction50Normal Internal Rotation90Normal External Rotation90Normal Normal (Degree)Patient (Degree) RIGHT HIP Flexion10060= 40% deficit Extension2010= 50% deficit Internal Rotation205= 75% deficit External Rotation3010= 67% deficit ABduction2515= 40% deficit ADduction155= 67% deficit LEFT HIP Flexion100Normal Extension20Normal Internal Rotation20Normal External Rotation30Normal ABduction25Normal ADduction15Normal Antalgia: Anterior, moderate Skin: Appears warm and dry and well oxygenated Psychiatric: Alert and oriented to person, place and time. There is normal mood and affect. Prognosis: The patient's prognosis is undetermined, treatment is indicated. Patient education/Home Care Instructions I have discussed with the patient the diagnosis of MTBI or Mild Traumatic Brain Injury and how this correlates with their symptoms. We reviewed the mechanism of their injury and the concept of Coupe Contracoupe injury and the trauma it produced on the brain. We reviewed referral to a neurologist for further evaluation. Casual Relationship Mhas sustained significant injuries to her spine as a result of the injury on 7/11/18. If it were not for the accident she would not have required examination, diagnostic testing or treatment. Mwas in a normal state of good health and functioning at full capacity in both her personal life prior to this injury. The patient’s bodily injuries are consistent with the patient’s history of accident. Greater than 50% of the encounter was spent coordinating care and counseling the patient. The total visitation exceeded 45 minutes. Thank you for the opportunity to provide this report. If you require certification, please contact my office at-. Respectfully,