Sample Name: Chiropractic Initial Evaluation - 1
Description: Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.
(Medical Transcription Sample Report)
HISTORY OF PRESENT COMPLAINT: Ms. Abc initially visited our office for the purpose of consultation and examination on December 1, 2004. Ms. Abc states that on November 16, 2004, she was in a parking lot, she was walking to her car, and stepped into a pothole. The patient reports that she fell backwards. The patient landed on her back and hit her head as well. The patient reports sudden, severe left ankle pain and low back pain as well as neck pain in the back of her head. The patient was unable to get up due to severe pain. The patient was afraid that she broke her left ankle. The patient eventually got up and went to her car. The patient went home and symptoms got worse. A few days later, the patient went to the hospital on November 21, 2004. The patient had x-rays of the lumbar spine, left ankle, and left foot. The patient was seen at Healthcare System. She was next seen by Rapid Rehabilitation on December 1, 2004.
PRESENT COMPLAINT: She presents today complaining of moderate to severe low back pain, neck pain, and left ankle pain.
PAST MEDICAL HISTORY: Ms. Abc states that before the accident on the above date, she would describe her health as good without disability. She denies any previous trauma to the lumbar, cervical, or left ankle.
SURGICAL HISTORY: None.
PHYSICAL EXAMINATION: The examination reveals a 51-year-old female. The heart is regular and the lungs are clear. The abdominal examination is within normal limits. Pulses are present for both upper and lower extremities.
HEAD AND TEMPOROMANDIBULAR JOINTS: There was no indication of facial bruises or scars of any kind. Examination of the temporomandibular apparatus was unremarkable. Jaw jerk reflexes were within normal limits.
CERVICAL SPINE: Ranges of motion of the cervical spine were limited by guarding and pain in most planes. Pain was exacerbated with right lateral flexion and right rotation contralaterally. Tenderness to digital pressure was noted throughout the neck, especially in the paravertebral musculature. Hypertonicity was also present. Tenderness was noted bilaterally over the articular pillars. The following special tests were positive: Compression test and shoulder distraction test reproduced the patient's complaint.
THORACOLUMBAR SPINE: Ranges of motion in the thoracolumbar region revealed moderate pain with flexion, extension, lateral bending, and rotation. Tenderness to digital pressure was noted at L4/L5/S1 disc interspace and at the lumbar paraspinal muscles bilaterally. Examination of the mid back revealed mid scapular tenderness left sided, and hypertonicity at the left rhomboids, major and minor. The following special tests were positive: Kemp's and straight leg raise on the left.
NEUROLOGIC EXAMINATION: Neurologic evaluation revealed the patient to be oriented x 3 and alert. Her speech was fluent and comprehension was excellent. Cranial nerves II through XII were found intact. Pupils were round, regular, equal, and reactive to light. No nystagmus was observed. Hearing was within normal limits. Motor test showed 5/5 strength throughout without drift, atrophy, or fasciculations. Muscle tone was within normal limits. Sensory examination showed no loss of pin, touch, proprioception, or vibration. All dermatomal levels of the upper and lower extremities tested equal. Dysdiadochokinesia and joint positioning senses were normal indicating no cerebellar dysfunction. No pathologic reflexes were elected. The gait was difficult due to the patient's ankle pain. The patient was unable to do any weightbearing onto her left foot due to her severe pain. Deep tendon reflexes were 1/2+ equal and bilateral in the upper and lower extremities with both toes downgoing.
RADIOGRAPHIC EXAMINATION: Radiographs were taken at Healthcare System on November 21, 2004. X-ray, two views of the lumbar spine, were taken. Two views of the lumbar spine demonstrate a grade I spondylolisthesis of L5 over S1. No acute fracture. Grade I spondylolisthesis and bilateral spondylosis at L5-S1 as described on previous MRI examination of January 28, 2004. X-ray of the left ankle report that there are no significant abnormalities demonstrated. There is no evidence of soft tissue swelling, arthritis, fractures, or effusion. Three-view of the left foot demonstrates calcaneal spurs. No acute fracture.
1. Lumbar intervertebral disc disorder with possible myelopathy.
2. Ankle sprain/strain, grade III.
3. Cervical sprain/strain.
PLAN AND PROGNOSIS: The prognosis for Ms. Abc is good. At this time, a program of chiropractic adjustments, physical therapy, and massage will be rendered for a period of four weeks. Treatment will include physical therapy, massage, hot packs, electrical stimulation, and adjustments to the lumbar, cervical, thoracic spine as well as the left ankle.
Keywords: chiropractic, compression, tenderness, ankle, ankle pain, cervical spine, consultation, examination, extremities, flexion, initial evaluation, interspace, low back pain, lumbar spine, neck pain, paraspinal, rotation, scapular, upper and lower extremities, ranges of motion, lower extremities, cervical, sprain/strain, lumbar, spine,