Report Master Chiropractic Narrative Report Sample
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Backmender Family Chiropractic
1234 Wholesome Lane, Suite 3
Anytown, FL 34698
Attn: Mr. James Smith
Re: Mr. Alvin Aarbag
Policy Holder: Mrs. Edna Aarbag
Policy No: 321321321
Claim No: j-j54g5
Dear Mr. Smith:
On August 24, 2014, Mr. Alvin Aarbag presented himself for an initial examination and
evaluation of his complaints stemming from a work related injury that he was involved in.
In order to explain the injuries sustained by Mr. Aarbag in the accident of July 10, 2014,
I am forwarding the following report containing the subjective and objective findings of
our initial evaluation, which was performed on August 24, 2014.
I am sending this report to you as a professional courtesy because Mr. Jones is a
patient of yours and I would like to give you the opportunity to call if you have any
DESCRIPTION OF INJURY:
The time was 10.30p on July 10, 2014. Mr. Aarbag stated that he was the driver in a
station wagon which was making a right turn at approximately 15 m.p.h. According to
the patient, the other vehicle involved was travelling at approximately 45 m.p.h. He
stated that the other vehicle struck his vehicle on the left front side.
Mr. Aarbag also reported that, at the time of the accident, the road conditions were
clean and dry and visibility was good. In addition, he stated the damage to his station
wagon was moderate. The estimated damage to the patient's vehicle was $15,000.
Damage to the other vehicle was totalled. He also stated that he did not see the
accident coming, and therefore was not braced for the impact. Also, he was wearing
his seat belt and had his shoulder harness on. On impact, the driver's forward, the
front passenger's forward and both their side air bags all deployed.
His station wagon was equipped with headrests, his own headrest being even with the
bottom of his head at the time of the accident. He also noted that he had his head
turned to the right at the moment of impact. The patient's body struck the inside of
his vehicle on impact, "My head and left shoulder struck my side window." He lost
consciousness for about 5 seconds during the accident. According to the patient, the
police showed up at the scene. An accident report was filled out at that time.
Immediately following the accident, the patient's main complaints included problems
with sleeping, pain behind his eyes, fatigue, anxiety, stiffness in the neck, headaches,
pain in the mid back, neck pain, dizziness and pain in the low back.
Following the accident Mr. Aarbag was taken by ambulance to the hospital emergency
room. Xrays were taken of his neck, back and left arm and shoulder, which revealed
no sign of fractures. Then Mr. Aarbag was treated with ice and the application of a
cervical collar. He was given a prescription for pain killers and released. On release
he was given instructions to alternate ice and heat on his neck and left shoulder.
HISTORY OF PRESENT ILLNESS (HPI):
PAST, FAMILY AND SOCIAL HISTORY (PFSH):
Mr. Aarbag indicated that he had not experienced prior symptoms similar to his current
complaints, and was symptom free at the time of the aforementioned accident of July 10,
I have determined that Mr. Aarbag’s history has not contributed to his present condition.
Prior Treatment Information:
The patient reported that prior to his first visit to our office, he saw Dr. James Jones,
whose specialty was orthopedic surgery. His first visit there was on August 13, 2013.
Xrays were performed at that time. During the 2 visits to that office, Mr. Aarbag
received examination only, which he reported had little, if any, benefit. The patient is
no longer receiving treatments at that office. His last visit there was on June 11, 2014.
Review of Systems (ROS):
An inventory of body systems was obtained through a series of questions and patient
responses, seeking to identify signs and/or symptoms which he may be experiencing
or which he has experienced.
Head Problems: The patient is currently complaining of dizziness, a recent head
trauma and headaches. He reports a personal history of head trauma and headaches.
He currently denies any personal history of dizziness. He reports a family history of
headaches. He denies any family history of dizziness or head trauma. Urinary
Problems: He reports a family history of headaches. He denies any family history
of dizziness or head trauma. Hearing Problems: The patient is currently complaining
of headaches. He reports a personal history of headaches. He reports a family history
SUBJECTIVE CHIEF COMPLAINTS (CC):
An assessment of Mr. Aarbag's current signs and symptoms was performed today.
His first symptom is dull and pounding bilateral temporal headaches. He stated the pain
is also excruciating. He reported that the pain radiates into the left side of the neck and
the left shoulder. It occurs between one half and three fourths of the time when he is
awake, and causes serious diminution in his capacity to carry out daily activities. He
further indicated the symptom is brought on by arising in the morning. It is aggravated
by bending to the right, straining and by jogging. Some relief is experienced by the time
Mr. Aarbag's second stated symptom is shooting, tingling and constricting pain in the
low back on the left side. He stated the pain is also exasperating. He stated that this
symptom radiates into the left leg and the left foot. It occurs between one fourth and
one half of the time when he is awake, is tolerated, but does cause some diminution in
his capacity to carry out daily activities. He further indicated the symptom is brought on
by twisting to the left. It is aggravated by twisting to the right and by straining. Some
relief is experienced by sitting.
He stated his third symptom is sharp, burning and cramping pain in the right shoulder.
He stated that this symptom radiates into the right arm. It occurs less than one fourth
of the time he is awake, is annoying but has not caused appreciable diminution in his
capacity to carry out daily activities. He further indicated the symptom is brought on by
lifting. It is aggravated by straining. Some relief is experienced by sitting.
ACTIVITIES OF DAILY LIVING ASSESSMENT:
Based on an assessment of Mr. Aarbag’s history, along with his subjective complaints,
objective findings, and other test results, it is evident from a standpoint of medical
certainty, that his current condition did result from the type of accident described in this
report. He reported suffering varying degrees of losses of functional capacity with the
With regard to Self Care and Personal Hygiene, Mr. Aarbag stated: taking out the trash
can be managed by himself, despite marked pain; bathing and preparing meals can be
done without much difficulty, despite some pain; drying his hair and putting on his
shoes can be done without difficulty.
With regard to Physical Activity, Mr. Aarbag stated: bending backward can be managed
alone, despite marked pain; twisting to the left can be done, but not without some
difficulty because of the resulting pain; leaning backwards can be performed without
With regard to Communication, Mr. Aarbag reported the following: his ability to
concentrate and speak are slightly affected by his condition; his ability to listen is
not affected by his condition.
GENERAL PHYSICAL EXAMINATION:
Mr. Aarbag is a right-handed mentally alert and cooperative male.
His superficial appearance did not indicate any obvious distress. Minor's Sign was not
present, tending to rule out sciatica.
Weight: 155.00 pounds. Stature: Average build. Height: 5 feet, 4 1/4 inches. Body
temperature: 98.9 degrees Fahrenheit;(normal).
Heart: No arrhythmia or murmurs were noted. Lungs: No rales, rhonchus or
wheezing were noted in any of the lobes of the lungs.
RANGE OF MOTION STUDIES:
The following joint range of motion calculations and analyses were performed to
determine Mr. Aarbag’s present condition with regard to joint motion.
Flexion, 54 degrees, Exceeds norm: norm is 50 degrees.
Extension, 54 degrees, Slight restriction: norm is 60 degrees.
Left Lateral Flexion, 44 degrees, Slight restriction: norm is 45 degrees.
Right Lateral Flexion, 42 degrees, Slight restriction: norm is 45 degrees.
Extension (Angle of Minimum Kyphosis), 54 degrees, norm is 0 to 59.
Flexion, 54 degrees, Slight restriction: norm is 60 degrees.
Left Rotation, 54 degrees, Exceeds norm: normal rotation is 30.
Flexion, 65 degrees, No Restriction: norm is 60+.
Extension, 22 degrees, Slight Restriction: norm is 25.
Left Lateral Flexion, 21 degrees, Slight restriction: norm is 25.
Right Lateral Flexion, 20 degrees, Slight restriction: norm is 25.
Head and Neck Muscles:
The Neck Flexor Muscle Group (Longus Colli and Capitis and Infra Hyoids) and Neck
Extensor Muscle Group (Splenius Capitis, Semispinalis Capitis, Suboccipitals and
Trapezius) were weak (Grade 4).
The left Lateral Flexor Muscle Group (Sternocleidomastoid and Scalenes) and right
Lateral Flexor Muscle Group (Sternocleidomastoid and Scalenes) were very weak
The left Rhomboid muscle group was weak (Grade 4).
The Levator Scapulae was very weak (Grade 3).
The right Rhomboid muscle group was strong (Grade 5).
The Levator Scapulae was weak (Grade 4).
Muscle Atrophy Evaluation: No evidence of muscle atrophy was found in the upper
or lower extremities, with one side being compared to the other.
Cervical Lesion Tests:
Bakody Sign, which is usually indicative of nerve root irritation, was present bilaterally.
This test is normally done with patients who have cervical radicular pain. The patient
actively places the palm of the affected extremity flat on the top of the head while raising
the elbow level with the head. When this action reduces or eliminates the radiating pain,
the sign is considered present.
The Cervical Distraction Test, which indicates nerve root compression, was positive
bilaterally. While seated, the patient actively rotates the head and neck until radicular
pain is produced. The examiner then rotates the head to the same extent but with
strong upward traction added to the motion. If this action performed by the examiner
gives relief or significantly reduces the patient's cervical and/or radicular pain, this test
is considered positive, indicating nerve root compression. If the patient can't actively
rotate the head or neck because of pain, the examiner can still do this test by adding
traction with or without rotation.
The Shoulder Depression Test, which is used to indicate either adhesions of the dural
sleeves, the spinal roots, or the adjacent structures of the shoulder joint capsule, was
positive on the left side. This test is done with the patient supine. The examiner
standing at the head of the patient, flexes the neck to the side opposite to the shoulder
being tested while pushing the shoulder caudadward. Then, while maintaining the
depression of the shoulder, the head is rotated, again to the side opposite to the
shoulder being tested. If radicular pain is either produced or aggravated by the first
action and then confirmed by the second, the test is considered positive.
Thoracic Lesion Tests:
The Chest Expansion Test, which is used to indicate thoracic fixation, was positive.
With the patient standing or sitting erect, the examiner takes a chest measurement with
the tape measure over the lowest part of the fourth intercostal space with the patient
maximally exhaling. The patient then maximally inhales and another measurement
is taken. Normal expansion for an adult male is at least two inches, and one and one-half inches for an adult female. Less than these amounts would be a positive test,
indicating thoracic fixation. This is considered an important sign in any ankylosing
condition such as Marie-Strumpell Disease.
Intervertebral Disc Syndromes:
Amoss’ Sign, which when positive indicates either Ankylosing Spondylitis, severe
sprain or Intervertebral Disc Syndrome, was present. This test is usually performed
on patients with dorsolumbar or lumbosacral complaints. The patient is made to lie
on his or her side and then is told to rise from the table. When this action of arising
from a recumbent position causes significant localized thoracic or lumbosacral pain,
the test is considered positive.
The patient's spine, extremities, gait, etc., were thoroughly inspected visually revealing
anomalies which included cervical muscle tension on the right side, a high scapula on
the right, lumbar muscle tension bilaterally, cervical kyphosis and a limp favoring the
Date of Study: August 11, 2014
The following films were available for review:
Mento Vertex (Base Posterior)
Left Anterior Oblique
Right Anterior Oblique
There is no evidence of fracture present. There are no significant anomalies. There are
no developmental distortions.
There is evidence of slight calcinosis of the abdominal aorta. Degenerative arthritis is
present. This is also known as osteoarthritis, which results from wear and tear and
trauma to the joints, usually evolving in middle age and most commonly affecting the
Palpation, which is an examination using the hands, was performed to evaluate
Mr. Aarbag's response to pressure and to examine tissue consistency.
In the neck, palpation of the inion (base of the occiput midline) demonstrated moderate
pain, mild biomechanical alterations, and mild induration.
Favorable results are expected for this patient. Mr. Aarbag is presently receiving
medically necessary therapeutic care, as he has not yet reached MMI. Since his last
visit, the patient has experienced some improvement.
Traumatic insult to the cervical spine with resultant brachial radiculopathy.
Traumatically induced sprain/strain of the cervical spine, with attendant radicular
Traumatic insult to the soft tissues of the neck and cervical paravertebral musculature
with accompanying radiculitis.
307.81 Tension headache
350.1 Trigeminal Neuralgia
716.9 Inflamation Shoulder
719.0 Cervical Facet Joint Swelling
PROGNOSIS: At this time, Mr. Aarbag's prognosis is good. His case is somewhat
complicated, but continued improvement is expected, despite permanent residuals
being a possibility. Mr. Aarbag’s condition is now in a chronic state. There is a high
probability that formed adhesions have resulted from the injuries that the patient has
suffered. With the fibrotic tissue that comes from such an injury, joint hypomobility
is usually the common sequela. This is evidenced by the loss of range of motion as
suffered by this patient.
Today's Modalities & Procedures: Following were the modalities used today:
chiropractic adjustment, Hubbard tank (97036), massage therapy (97124) for 60
minutes, therapeutic procedures (97110) for 30 minutes, and work hardening (97546)
for 1 hour, along with cervical collar, spinal traction, whirlpool treatment, intersegmental
traction and corrective spinal exercises.
The above was for the purpose of decreasing pain, returning the patient to his pre-clinical status, retarding degeneration and relieving symptoms of exacerbation.
FUTURE CARE PLAN:
Present Care Phase: Mr. Aarbag is presently in a relief phase of care.
Future Treatment Plan: Our recommended future care plan for this patient consists
of moist heat therapy, lumbar traction, spinal manipulation and chiropractic adjustments
two times a week for seven weeks.
Goals of Treatment Plan: The above treatment plan has the goal of decreasing pain,
decreasing spasms, increasing strength, stabilizing segments, increasing flexibility and
relieving symptoms of exacerbation.
Chronic pain is a self sustaining, self reinforcing, and self regenerating process. It is not
a symptom of an underlying acute somatic injury, but rather a destructive illness in its
own right. It is an illness of the whole person and not a disease caused by the
pathologic state of an organ system. Chronic pain is persistent, long lived, and
progressive. Pain perception is markedly enhanced. Pain related behavior becomes
maladaptive and grossly disproportional to any underlying noxious stimulus, which
usually has healed and no longer serves as an underlying pain generator.
Many medical doctors have found that chiropractic care is a very effective option for the
handling of a number of structural problems underlying various patient complaints. If
you would like further information regarding Mr. Aarbag or chiropractic care in general,
please feel free to contact me.
Dr. James C. Brown, D.C.
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