Preview
FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
EXHIBIT II
FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
BAK ‰IRO
Chiropractic Initial
Examination Report
O Health Plan, S No Fault, O Worker's Compensation
Date of Exam: 8-25-17
Patient's Name: ARUNDEL, ALICIA Gender: O Male B Female
Date of Birth: Phone/Email: 631-897-9317 / amarundel5@gmail.com
History
Date of Accident/Onset: 7-18-15
The Above named patient presented to this office for examination and treatment
for his/her pain. The information was obtained from the patient by his/her own
description.
Nature of Accident: O MVA, O Work-Related Accident, O Other:
The patient stated that:
Pt is a 26 YOF speech pathologist who reports neck pain, upper back pain, left shoulder and left elbow pain from MVA sustained on 7-18-15. pt reports that she was a
driver side passenger in a limosine that was hit by a vehicle as they were making a U-tum. Pt reports brief loss of consciousness. pt was taken to Stonybrook Hospital
were xrays revealed fracture to her left olecranon. pt was hospitalized for 16 days before surgery for her elbow was performed. pt reports she had occupational therapy
from August/2015-August/2016 at NYP and is still currently receiving treatment 1x/wk. pt is currently experiencing uInar nerve neuropathy whenever her arm is in a static
position for extended penods or with weight. pt descnbes her pain as constant, stiffness, achy and currently rates 5/10 on VAS but 10/10 at worst.
In MVA the patient was a: O O Passenger - O - O
Driver, Front, Passenger Back,
Pedestrian, O Bicycle Rider
Seatbelt O Yes, O No
The patient reported the following symptoms post-accident:
O Loss of consciousness, O Nausea and/or vomiting, O Other:
O Shock, O Blurred or double vision, O Dizziness, O Jaw and/or facial pain.
Symptoms Appeared: O Immediately, O Hours or Days after the accident
Hospital:
X-Ray/ CT Scan/ MRI performed:
Medical History
Trauma:
Surgical: Left olecranon removal, facial and finger laceration
Medical:
Allergy:
S All past medical history given by the patient appears to be non-contributory
According to the information presented by the patient, he/she was in a regular
state of good health and feeling before he/she was involved in this accident when
all of his/her symptoms began.
Presenting Complaints
Pain Chart
Headaches
O Temporal, O Occipital, O Frontal, O All around
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FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
Neck Pain & Stif fness:
Patient reports /10 on VAS E Left, O Right, E Both
With radiation to: E L/ ¡ R Shoulder, E L/ ¡ R Arm, E L/ ¡ R Fingers
Mid Back and Interscapular Pain & Stiffness:
Patient reports /10 on VAS O Left, O Right, E Both
Lower Back Pain & Stiffness
Patient reports _____/10 on VAS O Left, U Right, O Both
With radiation to:
O L/ O R Buttock, O L / O R Lower Extremities, O Other:
Chest Pain: ¡ Left ¡ Right O Sternum
Shoulder Pain & Stif fness: O Left O Right O Bilateral
Knee Pain & Stif fness: O Left O Right O Bilateral
Other:
Physical & Neurological Examination
The patient remained alert and responsive throughout the examination. The patient
followed all verbal commands.
Ambulation: E Normal, O Painful
Postural Analysis
Head tilt towards forward head carriage
Ear high on L
Cervical muscle cervicalerectorspinae BL. suboccipitalsBL, ant/midscalenesBL. uppertrapeziusBL, rhomboidsBL.pec minor/majorBL, lat dorsi BL
hypertonicity
Shoulder high on R
Thoracic/Lumbar thoracolumbar parespinals BL, psoas BL, QL BL, glut medius BL, hamstrings BL, rectus femoris BL, ITB/TFL BL, adductors BL
muscle hypertonicity
Ilium high on L
Deep Tendon Reflexes (Graded from 0 to +5, Normal +2)
C5 (Biceps) +2 BL
C6 (Brachioradialis) +22L
C7 (Triceps) +2BL
L4/L5 (Patella) +2BL
S1 (Achilles) +2BL
Pattern of Abnormal Sensation (+ Indicate a possible nerve pathology)
Hypoesthesia WNL
Hyperesthesia WNL
Paresthesia WNL
Anesthesia WNL
DERMATOME evaluation of C4 to T1 and T1 to S2 was NORMAL BILERATERALLY with the
exception of:
ORTHOPEDIC EXAMINATION
Cervical Spine
Shoulder Indicates the presence of (+) BL
Depression Test adhesions/injury to the soft tissues
adjacent to the cervical spine
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FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
SpurliT)g/Foraminal Elicited pain indicating presence of (+)
Compression Test nerve root lesion
Soto-Hall Test Elicited pairl indicating presence of py
vertebral trauma
Thoracic & Lumbar Spine
Lasegue Test/ Suggestive of a disc lesion, nerve (+)2L@ 40 degreeship flexion
Straight Leg root impingement or other pathology
Raise (SLR) in the lumbar spine
Braggards Test Indicating the presence of a disc (-)2L
protrusion of the lumbar spine with
nerve root irritation
Kemps Test Indicating the presence of vertebral (+)2L
trauma or disc bulge/herniation
Thomas Test Indicating the presence of hip (+) BLfor tight hip flexors
flexor tightness
...... .
Belt Test Indicating a lumbosacral injury p)
Valsalva Maneuver Indicating a cerical and/or lumbar
space occupying lesion
Nachlas (heel to Indicating a lesion of the lumbar (+)2L
buttock) test nerve roots
....
Ely's (heel to Indicating a lesion of the lumbar
opposite buttock) nerve roots
Test
Yeomans Test Indicating a sacroiliac injury
Patrick Fabere Indicating a hip injury
Test
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FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
Shoulder Tests
Apprehension Indicating a tendency of chronic
Tests glenohumeral dislocation
_____..._________
Speeds Test Indicating acute bicipital
tendonitis
______________________
_______ _____
Press Test Indicating supraspinatus
sprain/strain
_______ __
___ _____
Knee Tests
McMurray's Test Indicating meniscus tear
Anterior Drawer Indicates Anterior Cruciate Ligament
Sign (ACL) pathol.ogy
Posterior Drawer Indicates Posterior Cruciate
----
Sign Ligament (PCL ) Pathology
Lateral Stability Indicates Lateral Collateral
Test Ligament (LCL) pathology
Medial Stability Indicates Medial Collateral Ligament
Test (MCL) pathology
Range of Motion
Cervical Spine
Motion Tested Normal ROM Measured ROM Pain upon Pain upon
(Actively (Visually Minimal Movement Extremes of
Performed) Assessed) Movement
Flexion 60 40
Extension 50 20
Right Lateral 40
20
Flexion
Left Lateral 40 20
Flexion
Right Rotation 80 60
Left Rotation 80 60
Symptomatic Muscles: cervicalerectorspinae BL, suboccipitalsBL, ant/midscalenesBL, uppertrapeziusBL, rhomboidsBL, pec minor/majorBL, lat dorsi BL
Muscular Hypertonicity: ¡ None / ¡ Minimal / ® Moderate / ¡ Severe
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FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
Tenderness: Grade 3 /4 for all above mentioned muscles
Thoracic Spine
Motion Tested Normal ROM Measured ROM Pain upon Pain upon
(Actively (Visually Minimal Extremes of
Performed) Assessed) Movements Movement
Flexion 50 30
Extension 30 20
Symptomatic Muscles: . ..................__._
____ _______________________________________._____ __ ---
Muscular Hypertonicity: O None / O Minimal / Moderate / ¡ Severe
Tenderness: Grade a /4 for all above mentioned muscles
Lumbar Spine
Motion Tested Normal ROM Measured ROM Pain upon Pain upon
(Actively (Visually Minimal Movement Extremes of
Performed) Assessed) Movement
Flexion 90 70
Extension 30 10
Right Lateral 20
10
Flexion
Left Lateral 20 20
Flexion
Right Rotation 30 so
Left Rotation 30 20
Symptomatic Muscles: thoracolumber paraspinals BL, psoas BL, QL BL, glut medius BL, hamstrings BL, rectus femoris BL, iTB/TFL BL, adductors BL
Muscular Hypertonicity: ¡ None / ® Minimal / O Moderate / O Severe
Tenderness: Grade _2 _/4 for all above mentioned muscles
TREATMENT PLAN
Chiropractic manipulative treatment (CMT) is a form of manual treatment to influence
joint and neurological function. This treatment may be accomplished using a variety of
techniques. Treatment will consist of gentle chiropractic manipulation (or adjustments)
to the cervical/thoracic/lumbar spine, trigger point therapy and various stretching
techniques as per individual symptomology. I am prescribing a conservative chiropractic
spinal manipulative treatment projected for 1 months. The frequence of visits proposed
at the onset of treatment will be for 3-4 times per week and will be re-evaluated when
appropriate. I will educate the patient about his/her injuries along the course of their
treatment and also provide home exercises to supplement his/her chiropractic treatrnents.
Chiropractic spinal manipulaton is the method of treatment, which places emphasis on the
correction (or re-alignment) of those misaligned manipulation vertebrae, termed as
subluxations, that are resistant to proper motion. This treatment protocol has been
proven to be effective in the correction of interosseous disrelationsps to remove nerve
interference and restore particular function.
I certify and affirm that: (1) the above report is my own; (2) the statements contained
herein are true and accurate to the best of my knowledge; (3) any charges resulting from
the processing of this report by Brian Bak D.C. have been reviewed and approved by me.
Res fully S m'tted,
Brian Bal D
NYS Lic # X011168
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FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
8,g Date of Service: 2-21-19
BAK CHIRO Patient: ARUNDEL, ALICIA
Date of Accident: 7-18-15
Chiropractic Re-Evaluatio
Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT
SHOULDER PAIN, LEFT ELBOW PAIN. Pt reportsincreasedneck and back painsymptoms withincrease in left upper
extremitypainand stiffness
sinceher previoustreatment.pt currently
reportsthatherleft elbowfeels
decrease pain referral
into the
left elbow
Pain Scale: VAS 5 10
/
Physical Examination:
ROM: C Spine e WNL o Decrease a
T Spine a WNL a Decreased a
L Spine a WNL a Decreased a
+ Orthopedic Findings (+) SotoHall (+) Shoulder
depression BL (+) Cervical
compression/distraction hip flexion
(+) SLR at 40 degrees BL
(-)Braggards BL (+) Kemps BL (+)Thomas testfortighthipflexors BL (+)Obers BL (+) Nachles BL
WNL
Muscle weakness: Upper Extremities Lower Extremities Right Left
WNL
Hyperesthesia O
Hypoesthesia O
Paresthesia O Dermatome:
Anesthesia O
uuscism Ned nant BL nounalstningth,(+)painonpalpation,(+)painwithmovement.
(+)flexionintact,(+)extension rotahonintact,(+)kyphosis.
intact.(-)1ateral
Chiropractic Findings:
Backexam,BL:normal
skength(+)pain
onpalpation, (4)Roxion
(*)painwnhmovement. (+)amnsIon
Intact. 0pateral
intact. rotation4)Iordosis.
Intact. andmulliple
HypertonicHy trigger
poetsincervical
ereclor BL.suboccipitals
spinae BL,
ant/midacalenes
BL.uppertrapezlus BL latdorsiBL,thoracolumber
BL.pecminor/major
BL.rhomboids paraspinals BL,rectusfemorisBL ITBfFFL
BL,psoasBL,QLBL,glutmediusBL.hamstrings BL
BL.adductors
Chiropractic Treatment Pla
Frequency: |1 o | 2 o | 3 A | 4 o |5 o | time(s) per week
Duration: |1 o |2 o | 3 o | 4o | 6 O | 8 a | 12 o | weeks
Referral/Recommendation: Continue with CMT C/T/L-sp, softtissue treatment.active release treatment, physiotherapy modalities,
heat and prescribed exercise protocols to decrease pain and increase mobilityand ROM, inorder to regainfunctional capacity.
BHan Bak DC
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FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
Date of Service: 3-15-18
BAK ? CHIRO patient: ARUNDEL, ALICIA
Date of Accident: 7-18-15
Chiropractic Re-Evaluatio
Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT
SHOULDER PAIN, LEFT ELBOW PAIN. Pt reports
continuedimprovement in neckand back pain symptoms withdecreasein left upper pain
extremity
and atiffnesswith everytreatment.pt reportsinterrnittentpainreferralsoccurwith tossfrequencyand intensity.pt alsoreportsimprovedupper bodyInobilty and ROMwithmanualtreatments.
Pain Scale: VAS 5-6 / 10
Physical Examination:
ROM: C Spine s WNL o Decreased a
T Spine a WNL o Decreased a
L Spine a WNL o Decreased a
+ Orthopedic Findings (+) SotoHall (+) Shoulder
depression BL (+) Cervical
compression/distraction
(+) SLR hip flexion
at 40 degrees BL
(-)Braggards BL (+) Kemps BL (+) Thomas testfortighthipflexors BL (+)Obers BL (+) Nachlas BL
WNL
Muscle weaknes Upper Extrernities Lower Extremities Right Left
WNL .
Hyperesthesia O
Hypoesthesia O
Paresthesia O Dermatome:
Anesthesia O
uusc,s8µLNeckexam.BL normalstrength,(+)panonpalpation,(+)painwithmovement, intact,(-)1ateral
(+)flexionintact,(+)extensionrotationhtact,(+)kyphosis
Chiropractic Findings:
Backexam,BL:normal
streng1rt, (+)pain
(")painonpalpation, (+)nexion
withmovement. (+)extenskm
antact. 6)lateral
InIact, intact4)Iordosis.
solation pointsIncervicat
assmutlpleIngger
HypertonIcity erecarspinae
BL,suboccepdals
BL,
anumed BL,uppertrapezius
scalenes BL.pecminor/major
BL.shombolds paraspinals
BL.latdorstBL.thoracolumberBL,psoasBL,QLBL,glutmediusBL,hamstnngs
BL.rectusfemonsBL.ITB/TFL BL
BL,adductors
Chiropractic Treatment Pla
Frequency: o | 2 o | 3 A | 4 a |5 o |time(s) per week
Duration: |1 o | 2o | 3 o | 4 o | 6 A | 8 o | 12 o | weeks
Referral/Recommendation: Continue with CMT C/T/L-sp. softtissue treatment,active release treatment, physiotherapy rnodalities,
heat and prescribed exercise protocols to decrease pain and increase mobilityand ROM, inorder to regainfunctional capacity.
000009
FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
Date of Service: s-2-39
BAK $ CHIRD Patient: ARUNDEL, ALICIA
Date of Accident: 7-18-15
Chiropractic Re-Evaluation
Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT
SHOULDER PAIN,LEFTELBOWPAIN Ptreportsimprovement
in neckandbackpainSymptoms pl reportsincrease
withdecreasein feftupperextremitypainandstiffnesswitheverytreatment.Currently.
painanddiscomfortin herneckandupperthoracicregion,pt reportsincreasein spinalrnobilityendROMwithincreasefunctionalcapacitymcludingcomputeruseforlongerperiodawithoutreferredpain
Pain Scale: VAS 4 10
/
Physical Examination
ROM: C Spine a WNL o Decreased s
T Spine a WNL o Decreased s
L Spine a WNL o Decreased a
+ Orthopedic Findings (+) SotoHall (+) Shoulder
depressionBL (+) Cervical
compression/distraction
(+) SLR hip flexion
at 40 degrees BL
(-)Braggards BL (+) Kemps BL (+)Thomas testfortighthip flexorsBL (+)Obers BL (+) Nachlas BL
WNL
Muscle weakne Upper Extremities Lower Extremities Right Left
WNL .
Hyperesthesia O
Hypoesthesi O
Paresthesia O Dermatome:
Anesthesia O
uusc/sm (+)painon palpation,(+)painwth movemerf
Neckexem,Be nonnaistrength, intact,(-)Interalrotationintact,(+}kyphosts
, (+ylexionintact,(+)extension
Chiropractic Findings:
Backexam.
BL:normal (+)pain
strength, (+)pain
onpalpation,withmovement,
(+)flexion
(+)endensson
intact, inisct,(-)lateral
mtahon (-)1ordosis.
Intact, andmuniple
Hypedonicity trigger spinae
pointsincervical
erector BL,subocciptats
BL,
BL,uppertrapezius
ant/midscalenes BL,pecminor/major
BL.thomboids BL,latdorsiBL,thoracolumbar
paraspinals
BL,psoasBL,QLBL glutmediusBL,hamstrings
BL rectusfemonsBL,ITB/rFLBL,adductors
8L
Chiropractic Treatment Pla
Frequency: o | 2 o | 3 A | 4 o | 5 o | time(s) per week
Duration: 11 o | 2 o I 3 ¤ | 4 o |6 A | 8 o | 12 o |weeks
Referral/Recommendation: Continue with CMT C/T/L-sp, softtissue treatment,active release treatment, physiotherapy modalities,
heat and prescribed exercise protocolsto decrease pain and increase mobilityand ROM, inorder to regainfunctional capacity.
BrianBak DC
000010
FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
0 / Date of Service: 6-14-18
,,
BAK $ CH I RO Patient: ARUNDEL, ALICIA
Date of Accident: 7-18-15
Chiropractic Re-Evaluati
Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT
SHOULDER PAIN, LEFT ELBOW PAIN. Pt reports
increasedneck and back painsyrnptorns withincrease in left upper
extremitypainand stiffness
sinceher previoustreatment.pt currently
reportsthather left elbow
feels
decrease pain referral
into the left elbow
Pain Scale: VAS 5 / 1
Physical Examination:
ROM: C Spine a WNL o Decreased a
T Spine a WNL o Decreased e
L Spine a WNL o Decrease a
+ Orthopedic Findings (+) SotoHall (+) Shoulder
depressionBL (+) Cervical
cornpression/distraction
(+) SLRat 40 degreeship nexion
BL
(-)Braggards BL (+) Kemps BL (+) Thomas testfortighthip flexorsBL (+)Obers BL (+)Nachlas BL
WNL
Muscle weakness Upper Extremities Lower Extremities Right Left
WNL
Hyperesthesia O
Hypoesthe O
Paresthesia O Dermatome:
Anesthesia O
uusc,s8EL (+)flexionintact.(+)axtension
Neckexam.BL nonnelstrength,(+)painonpalpation.(+)Áainwdhmovement, intact.(-)lateralrelationntact,(+)kyphosis
Chiropractic Findings:
Backexam,BL:normal (+)pain
strengdt,onpalpation.
(*)painwditmovement,
(+)flowon
btact.(+)emension
(-)lateral
Ingact, rotation (-)Iordosis.
Intact. andmultiple
Hypertonicity trigger
points qrector
stconncal sphine
BL,subocdpitals
BL,
ant/midscalenes BL,thomboids
BL.uppertrapezius BL pecminor/major paraspinals
BL,tatdorsiBL.thoracolumbarBL,psonsBL.OLBL glutmediusBL,hamainngs
BL rectusfemorbs BL,adductors
BL.ITB/TFL BL
Chiropractic Treatment Plan:
Frequency: |1 o | 2o | 3 5 | 4 a | 5 a | time(s) per week
Duration: o | 2o |3 o | 4o | 6 A I 8 o | 12 o | weeks
Referral/Recommendation: Continue with CMT C/T/L-sp, softtissuetreatment, active release treatment,physiotherapy modalities,
heat and prescribed exercise protocols to decrease pain and increase mobilityand ROM, in orderto regain functionalcapacity.
BrianBak DC
000011
FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
Date of Service: 7-31-18
BAK *
CHI RO Patient: ARUNDEL, ALICIA
Date of Accident: 7-18-15
Chiropractic Re-Evaluation
Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT
SHOULDER PAIN, LEFT ELBOW PAIN.pt reports
continuedimprovement in neck and back pains with every treatment
pt reports
decreaseand intermittent
pain referrals left elbow.
to the pt alsoreportsimproved upper body and
mobility ROM withmanual treatrnents.
Pain Scale: VAS 5 / 1
Physical Examination:
ROM: CSpine a WNL o Decrease a
T Spine a WNL o Decreased s
L Spine e WNL o Decreased a
+ Orthopedic FindingS (+) SotoHall (+) Shoulder
depression BL (+) Cervical hip flexion
(+) SLR at 40 degrees
compression/distraction BL
(-)Braggards BL (+) Kernps BL (+) Thomas testfortighthipflexors BL (+) Obers BL (+) Nachlas BL
WNL
Muscle weakness: Upper Extremities Lower Extremities Right Left_
WNL .
Hyperesthesia O
Hypoesthesia O
Paresthesia O Dermatome:
Anesthesia El
uusc,sia Nec×mani.Benonnelswenoinminonpavanonahwahmoanenunra×onwacianatenswniaemiaiaranolauonwactannyphosts
Chiropractic Findings:
Backexam,BL:normal (+)pain
attength, (")psmwithmovement,
onpalpalion, (+)Aemon (+)edension
m1act. Hlateral
mtact. rotation trigger
intact. IonfosisHypertonicRy
sadmultiplepoints erector
mcervical apinae
BL,suboccipitals
BL.
80,uppertrapezms
ant/midscalenes BL latdorsiBL,thoracolumbar
BL,pecminor/major
BL,thomboids BL,pscasBL,QLBL,glulmediusBL,hamstnngs
paraspinals BL,rectusfemonsBL,IT8/rFLBL,adductors
BL
Chiropractic Treatment Plan:
Frequency: |1 o | 2o |3 A | 4 o |5 o |time(s) per week
Duration: | o | 2o | 3 o | 4 o | 6 A | 8 o | 12 o | weeks
Referral/Recommendation: Continue with CMT C/T/L-sp, softtissue treatment, activerelease treatment, physiotherapy modalities,
heat and prescribed exercise protocols to decrease pain and increase mobility and ROM, in orderto regain functionalcapacity,
BrianBak DC
000012
FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015
NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022
Date of Service: 12-5-17
I . .
BAK f CHARO Patient: ARUNDEL, ALICIA
Date of Accident:
Chiropractic Re-Evaluat
Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT
SHOULDER PAIN, LEFT EL8OW PAIN Pt reports
continued improvement in neckand back painsymptoms withdecrease upper
in left pain
Preview
FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 EXHIBIT II FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 BAK ‰IRO Chiropractic Initial Examination Report O Health Plan, S No Fault, O Worker's Compensation Date of Exam: 8-25-17 Patient's Name: ARUNDEL, ALICIA Gender: O Male B Female Date of Birth: Phone/Email: 631-897-9317 / amarundel5@gmail.com History Date of Accident/Onset: 7-18-15 The Above named patient presented to this office for examination and treatment for his/her pain. The information was obtained from the patient by his/her own description. Nature of Accident: O MVA, O Work-Related Accident, O Other: The patient stated that: Pt is a 26 YOF speech pathologist who reports neck pain, upper back pain, left shoulder and left elbow pain from MVA sustained on 7-18-15. pt reports that she was a driver side passenger in a limosine that was hit by a vehicle as they were making a U-tum. Pt reports brief loss of consciousness. pt was taken to Stonybrook Hospital were xrays revealed fracture to her left olecranon. pt was hospitalized for 16 days before surgery for her elbow was performed. pt reports she had occupational therapy from August/2015-August/2016 at NYP and is still currently receiving treatment 1x/wk. pt is currently experiencing uInar nerve neuropathy whenever her arm is in a static position for extended penods or with weight. pt descnbes her pain as constant, stiffness, achy and currently rates 5/10 on VAS but 10/10 at worst. In MVA the patient was a: O O Passenger - O - O Driver, Front, Passenger Back, Pedestrian, O Bicycle Rider Seatbelt O Yes, O No The patient reported the following symptoms post-accident: O Loss of consciousness, O Nausea and/or vomiting, O Other: O Shock, O Blurred or double vision, O Dizziness, O Jaw and/or facial pain. Symptoms Appeared: O Immediately, O Hours or Days after the accident Hospital: X-Ray/ CT Scan/ MRI performed: Medical History Trauma: Surgical: Left olecranon removal, facial and finger laceration Medical: Allergy: S All past medical history given by the patient appears to be non-contributory According to the information presented by the patient, he/she was in a regular state of good health and feeling before he/she was involved in this accident when all of his/her symptoms began. Presenting Complaints Pain Chart Headaches O Temporal, O Occipital, O Frontal, O All around 000003 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 Neck Pain & Stif fness: Patient reports /10 on VAS E Left, O Right, E Both With radiation to: E L/ ¡ R Shoulder, E L/ ¡ R Arm, E L/ ¡ R Fingers Mid Back and Interscapular Pain & Stiffness: Patient reports /10 on VAS O Left, O Right, E Both Lower Back Pain & Stiffness Patient reports _____/10 on VAS O Left, U Right, O Both With radiation to: O L/ O R Buttock, O L / O R Lower Extremities, O Other: Chest Pain: ¡ Left ¡ Right O Sternum Shoulder Pain & Stif fness: O Left O Right O Bilateral Knee Pain & Stif fness: O Left O Right O Bilateral Other: Physical & Neurological Examination The patient remained alert and responsive throughout the examination. The patient followed all verbal commands. Ambulation: E Normal, O Painful Postural Analysis Head tilt towards forward head carriage Ear high on L Cervical muscle cervicalerectorspinae BL. suboccipitalsBL, ant/midscalenesBL. uppertrapeziusBL, rhomboidsBL.pec minor/majorBL, lat dorsi BL hypertonicity Shoulder high on R Thoracic/Lumbar thoracolumbar parespinals BL, psoas BL, QL BL, glut medius BL, hamstrings BL, rectus femoris BL, ITB/TFL BL, adductors BL muscle hypertonicity Ilium high on L Deep Tendon Reflexes (Graded from 0 to +5, Normal +2) C5 (Biceps) +2 BL C6 (Brachioradialis) +22L C7 (Triceps) +2BL L4/L5 (Patella) +2BL S1 (Achilles) +2BL Pattern of Abnormal Sensation (+ Indicate a possible nerve pathology) Hypoesthesia WNL Hyperesthesia WNL Paresthesia WNL Anesthesia WNL DERMATOME evaluation of C4 to T1 and T1 to S2 was NORMAL BILERATERALLY with the exception of: ORTHOPEDIC EXAMINATION Cervical Spine Shoulder Indicates the presence of (+) BL Depression Test adhesions/injury to the soft tissues adjacent to the cervical spine 000004 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 SpurliT)g/Foraminal Elicited pain indicating presence of (+) Compression Test nerve root lesion Soto-Hall Test Elicited pairl indicating presence of py vertebral trauma Thoracic & Lumbar Spine Lasegue Test/ Suggestive of a disc lesion, nerve (+)2L@ 40 degreeship flexion Straight Leg root impingement or other pathology Raise (SLR) in the lumbar spine Braggards Test Indicating the presence of a disc (-)2L protrusion of the lumbar spine with nerve root irritation Kemps Test Indicating the presence of vertebral (+)2L trauma or disc bulge/herniation Thomas Test Indicating the presence of hip (+) BLfor tight hip flexors flexor tightness ...... . Belt Test Indicating a lumbosacral injury p) Valsalva Maneuver Indicating a cerical and/or lumbar space occupying lesion Nachlas (heel to Indicating a lesion of the lumbar (+)2L buttock) test nerve roots .... Ely's (heel to Indicating a lesion of the lumbar opposite buttock) nerve roots Test Yeomans Test Indicating a sacroiliac injury Patrick Fabere Indicating a hip injury Test 000005 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 Shoulder Tests Apprehension Indicating a tendency of chronic Tests glenohumeral dislocation _____..._________ Speeds Test Indicating acute bicipital tendonitis ______________________ _______ _____ Press Test Indicating supraspinatus sprain/strain _______ __ ___ _____ Knee Tests McMurray's Test Indicating meniscus tear Anterior Drawer Indicates Anterior Cruciate Ligament Sign (ACL) pathol.ogy Posterior Drawer Indicates Posterior Cruciate ---- Sign Ligament (PCL ) Pathology Lateral Stability Indicates Lateral Collateral Test Ligament (LCL) pathology Medial Stability Indicates Medial Collateral Ligament Test (MCL) pathology Range of Motion Cervical Spine Motion Tested Normal ROM Measured ROM Pain upon Pain upon (Actively (Visually Minimal Movement Extremes of Performed) Assessed) Movement Flexion 60 40 Extension 50 20 Right Lateral 40 20 Flexion Left Lateral 40 20 Flexion Right Rotation 80 60 Left Rotation 80 60 Symptomatic Muscles: cervicalerectorspinae BL, suboccipitalsBL, ant/midscalenesBL, uppertrapeziusBL, rhomboidsBL, pec minor/majorBL, lat dorsi BL Muscular Hypertonicity: ¡ None / ¡ Minimal / ® Moderate / ¡ Severe 000006 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 Tenderness: Grade 3 /4 for all above mentioned muscles Thoracic Spine Motion Tested Normal ROM Measured ROM Pain upon Pain upon (Actively (Visually Minimal Extremes of Performed) Assessed) Movements Movement Flexion 50 30 Extension 30 20 Symptomatic Muscles: . ..................__._ ____ _______________________________________._____ __ --- Muscular Hypertonicity: O None / O Minimal / Moderate / ¡ Severe Tenderness: Grade a /4 for all above mentioned muscles Lumbar Spine Motion Tested Normal ROM Measured ROM Pain upon Pain upon (Actively (Visually Minimal Movement Extremes of Performed) Assessed) Movement Flexion 90 70 Extension 30 10 Right Lateral 20 10 Flexion Left Lateral 20 20 Flexion Right Rotation 30 so Left Rotation 30 20 Symptomatic Muscles: thoracolumber paraspinals BL, psoas BL, QL BL, glut medius BL, hamstrings BL, rectus femoris BL, iTB/TFL BL, adductors BL Muscular Hypertonicity: ¡ None / ® Minimal / O Moderate / O Severe Tenderness: Grade _2 _/4 for all above mentioned muscles TREATMENT PLAN Chiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurological function. This treatment may be accomplished using a variety of techniques. Treatment will consist of gentle chiropractic manipulation (or adjustments) to the cervical/thoracic/lumbar spine, trigger point therapy and various stretching techniques as per individual symptomology. I am prescribing a conservative chiropractic spinal manipulative treatment projected for 1 months. The frequence of visits proposed at the onset of treatment will be for 3-4 times per week and will be re-evaluated when appropriate. I will educate the patient about his/her injuries along the course of their treatment and also provide home exercises to supplement his/her chiropractic treatrnents. Chiropractic spinal manipulaton is the method of treatment, which places emphasis on the correction (or re-alignment) of those misaligned manipulation vertebrae, termed as subluxations, that are resistant to proper motion. This treatment protocol has been proven to be effective in the correction of interosseous disrelationsps to remove nerve interference and restore particular function. I certify and affirm that: (1) the above report is my own; (2) the statements contained herein are true and accurate to the best of my knowledge; (3) any charges resulting from the processing of this report by Brian Bak D.C. have been reviewed and approved by me. Res fully S m'tted, Brian Bal D NYS Lic # X011168 000007 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 8,g Date of Service: 2-21-19 BAK CHIRO Patient: ARUNDEL, ALICIA Date of Accident: 7-18-15 Chiropractic Re-Evaluatio Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT SHOULDER PAIN, LEFT ELBOW PAIN. Pt reportsincreasedneck and back painsymptoms withincrease in left upper extremitypainand stiffness sinceher previoustreatment.pt currently reportsthatherleft elbowfeels decrease pain referral into the left elbow Pain Scale: VAS 5 10 / Physical Examination: ROM: C Spine e WNL o Decrease a T Spine a WNL a Decreased a L Spine a WNL a Decreased a + Orthopedic Findings (+) SotoHall (+) Shoulder depression BL (+) Cervical compression/distraction hip flexion (+) SLR at 40 degrees BL (-)Braggards BL (+) Kemps BL (+)Thomas testfortighthipflexors BL (+)Obers BL (+) Nachles BL WNL Muscle weakness: Upper Extremities Lower Extremities Right Left WNL Hyperesthesia O Hypoesthesia O Paresthesia O Dermatome: Anesthesia O uuscism Ned nant BL nounalstningth,(+)painonpalpation,(+)painwithmovement. (+)flexionintact,(+)extension rotahonintact,(+)kyphosis. intact.(-)1ateral Chiropractic Findings: Backexam,BL:normal skength(+)pain onpalpation, (4)Roxion (*)painwnhmovement. (+)amnsIon Intact. 0pateral intact. rotation4)Iordosis. Intact. andmulliple HypertonicHy trigger poetsincervical ereclor BL.suboccipitals spinae BL, ant/midacalenes BL.uppertrapezlus BL latdorsiBL,thoracolumber BL.pecminor/major BL.rhomboids paraspinals BL,rectusfemorisBL ITBfFFL BL,psoasBL,QLBL,glutmediusBL.hamstrings BL BL.adductors Chiropractic Treatment Pla Frequency: |1 o | 2 o | 3 A | 4 o |5 o | time(s) per week Duration: |1 o |2 o | 3 o | 4o | 6 O | 8 a | 12 o | weeks Referral/Recommendation: Continue with CMT C/T/L-sp, softtissue treatment.active release treatment, physiotherapy modalities, heat and prescribed exercise protocols to decrease pain and increase mobilityand ROM, inorder to regainfunctional capacity. BHan Bak DC 000008 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 Date of Service: 3-15-18 BAK ? CHIRO patient: ARUNDEL, ALICIA Date of Accident: 7-18-15 Chiropractic Re-Evaluatio Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT SHOULDER PAIN, LEFT ELBOW PAIN. Pt reports continuedimprovement in neckand back pain symptoms withdecreasein left upper pain extremity and atiffnesswith everytreatment.pt reportsinterrnittentpainreferralsoccurwith tossfrequencyand intensity.pt alsoreportsimprovedupper bodyInobilty and ROMwithmanualtreatments. Pain Scale: VAS 5-6 / 10 Physical Examination: ROM: C Spine s WNL o Decreased a T Spine a WNL o Decreased a L Spine a WNL o Decreased a + Orthopedic Findings (+) SotoHall (+) Shoulder depression BL (+) Cervical compression/distraction (+) SLR hip flexion at 40 degrees BL (-)Braggards BL (+) Kemps BL (+) Thomas testfortighthipflexors BL (+)Obers BL (+) Nachlas BL WNL Muscle weaknes Upper Extrernities Lower Extremities Right Left WNL . Hyperesthesia O Hypoesthesia O Paresthesia O Dermatome: Anesthesia O uusc,s8µLNeckexam.BL normalstrength,(+)panonpalpation,(+)painwithmovement, intact,(-)1ateral (+)flexionintact,(+)extensionrotationhtact,(+)kyphosis Chiropractic Findings: Backexam,BL:normal streng1rt, (+)pain (")painonpalpation, (+)nexion withmovement. (+)extenskm antact. 6)lateral InIact, intact4)Iordosis. solation pointsIncervicat assmutlpleIngger HypertonIcity erecarspinae BL,suboccepdals BL, anumed BL,uppertrapezius scalenes BL.pecminor/major BL.shombolds paraspinals BL.latdorstBL.thoracolumberBL,psoasBL,QLBL,glutmediusBL,hamstnngs BL.rectusfemonsBL.ITB/TFL BL BL,adductors Chiropractic Treatment Pla Frequency: o | 2 o | 3 A | 4 a |5 o |time(s) per week Duration: |1 o | 2o | 3 o | 4 o | 6 A | 8 o | 12 o | weeks Referral/Recommendation: Continue with CMT C/T/L-sp. softtissue treatment,active release treatment, physiotherapy rnodalities, heat and prescribed exercise protocols to decrease pain and increase mobilityand ROM, inorder to regainfunctional capacity. 000009 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 Date of Service: s-2-39 BAK $ CHIRD Patient: ARUNDEL, ALICIA Date of Accident: 7-18-15 Chiropractic Re-Evaluation Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT SHOULDER PAIN,LEFTELBOWPAIN Ptreportsimprovement in neckandbackpainSymptoms pl reportsincrease withdecreasein feftupperextremitypainandstiffnesswitheverytreatment.Currently. painanddiscomfortin herneckandupperthoracicregion,pt reportsincreasein spinalrnobilityendROMwithincreasefunctionalcapacitymcludingcomputeruseforlongerperiodawithoutreferredpain Pain Scale: VAS 4 10 / Physical Examination ROM: C Spine a WNL o Decreased s T Spine a WNL o Decreased s L Spine a WNL o Decreased a + Orthopedic Findings (+) SotoHall (+) Shoulder depressionBL (+) Cervical compression/distraction (+) SLR hip flexion at 40 degrees BL (-)Braggards BL (+) Kemps BL (+)Thomas testfortighthip flexorsBL (+)Obers BL (+) Nachlas BL WNL Muscle weakne Upper Extremities Lower Extremities Right Left WNL . Hyperesthesia O Hypoesthesi O Paresthesia O Dermatome: Anesthesia O uusc/sm (+)painon palpation,(+)painwth movemerf Neckexem,Be nonnaistrength, intact,(-)Interalrotationintact,(+}kyphosts , (+ylexionintact,(+)extension Chiropractic Findings: Backexam. BL:normal (+)pain strength, (+)pain onpalpation,withmovement, (+)flexion (+)endensson intact, inisct,(-)lateral mtahon (-)1ordosis. Intact, andmuniple Hypedonicity trigger spinae pointsincervical erector BL,subocciptats BL, BL,uppertrapezius ant/midscalenes BL,pecminor/major BL.thomboids BL,latdorsiBL,thoracolumbar paraspinals BL,psoasBL,QLBL glutmediusBL,hamstrings BL rectusfemonsBL,ITB/rFLBL,adductors 8L Chiropractic Treatment Pla Frequency: o | 2 o | 3 A | 4 o | 5 o | time(s) per week Duration: 11 o | 2 o I 3 ¤ | 4 o |6 A | 8 o | 12 o |weeks Referral/Recommendation: Continue with CMT C/T/L-sp, softtissue treatment,active release treatment, physiotherapy modalities, heat and prescribed exercise protocolsto decrease pain and increase mobilityand ROM, inorder to regainfunctional capacity. BrianBak DC 000010 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 0 / Date of Service: 6-14-18 ,, BAK $ CH I RO Patient: ARUNDEL, ALICIA Date of Accident: 7-18-15 Chiropractic Re-Evaluati Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT SHOULDER PAIN, LEFT ELBOW PAIN. Pt reports increasedneck and back painsyrnptorns withincrease in left upper extremitypainand stiffness sinceher previoustreatment.pt currently reportsthather left elbow feels decrease pain referral into the left elbow Pain Scale: VAS 5 / 1 Physical Examination: ROM: C Spine a WNL o Decreased a T Spine a WNL o Decreased e L Spine a WNL o Decrease a + Orthopedic Findings (+) SotoHall (+) Shoulder depressionBL (+) Cervical cornpression/distraction (+) SLRat 40 degreeship nexion BL (-)Braggards BL (+) Kemps BL (+) Thomas testfortighthip flexorsBL (+)Obers BL (+)Nachlas BL WNL Muscle weakness Upper Extremities Lower Extremities Right Left WNL Hyperesthesia O Hypoesthe O Paresthesia O Dermatome: Anesthesia O uusc,s8EL (+)flexionintact.(+)axtension Neckexam.BL nonnelstrength,(+)painonpalpation.(+)Áainwdhmovement, intact.(-)lateralrelationntact,(+)kyphosis Chiropractic Findings: Backexam,BL:normal (+)pain strengdt,onpalpation. (*)painwditmovement, (+)flowon btact.(+)emension (-)lateral Ingact, rotation (-)Iordosis. Intact. andmultiple Hypertonicity trigger points qrector stconncal sphine BL,subocdpitals BL, ant/midscalenes BL,thomboids BL.uppertrapezius BL pecminor/major paraspinals BL,tatdorsiBL.thoracolumbarBL,psonsBL.OLBL glutmediusBL,hamainngs BL rectusfemorbs BL,adductors BL.ITB/TFL BL Chiropractic Treatment Plan: Frequency: |1 o | 2o | 3 5 | 4 a | 5 a | time(s) per week Duration: o | 2o |3 o | 4o | 6 A I 8 o | 12 o | weeks Referral/Recommendation: Continue with CMT C/T/L-sp, softtissuetreatment, active release treatment,physiotherapy modalities, heat and prescribed exercise protocols to decrease pain and increase mobilityand ROM, in orderto regain functionalcapacity. BrianBak DC 000011 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 Date of Service: 7-31-18 BAK * CHI RO Patient: ARUNDEL, ALICIA Date of Accident: 7-18-15 Chiropractic Re-Evaluation Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT SHOULDER PAIN, LEFT ELBOW PAIN.pt reports continuedimprovement in neck and back pains with every treatment pt reports decreaseand intermittent pain referrals left elbow. to the pt alsoreportsimproved upper body and mobility ROM withmanual treatrnents. Pain Scale: VAS 5 / 1 Physical Examination: ROM: CSpine a WNL o Decrease a T Spine a WNL o Decreased s L Spine e WNL o Decreased a + Orthopedic FindingS (+) SotoHall (+) Shoulder depression BL (+) Cervical hip flexion (+) SLR at 40 degrees compression/distraction BL (-)Braggards BL (+) Kernps BL (+) Thomas testfortighthipflexors BL (+) Obers BL (+) Nachlas BL WNL Muscle weakness: Upper Extremities Lower Extremities Right Left_ WNL . Hyperesthesia O Hypoesthesia O Paresthesia O Dermatome: Anesthesia El uusc,sia Nec×mani.Benonnelswenoinminonpavanonahwahmoanenunra×onwacianatenswniaemiaiaranolauonwactannyphosts Chiropractic Findings: Backexam,BL:normal (+)pain attength, (")psmwithmovement, onpalpalion, (+)Aemon (+)edension m1act. Hlateral mtact. rotation trigger intact. IonfosisHypertonicRy sadmultiplepoints erector mcervical apinae BL,suboccipitals BL. 80,uppertrapezms ant/midscalenes BL latdorsiBL,thoracolumbar BL,pecminor/major BL,thomboids BL,pscasBL,QLBL,glulmediusBL,hamstnngs paraspinals BL,rectusfemonsBL,IT8/rFLBL,adductors BL Chiropractic Treatment Plan: Frequency: |1 o | 2o |3 A | 4 o |5 o |time(s) per week Duration: | o | 2o | 3 o | 4 o | 6 A | 8 o | 12 o | weeks Referral/Recommendation: Continue with CMT C/T/L-sp, softtissue treatment, activerelease treatment, physiotherapy modalities, heat and prescribed exercise protocols to decrease pain and increase mobility and ROM, in orderto regain functionalcapacity, BrianBak DC 000012 FILED: SUFFOLK COUNTY CLERK 09/02/2022 02:47 PM INDEX NO. 611214/2015 NYSCEF DOC. NO. 986 RECEIVED NYSCEF: 09/02/2022 Date of Service: 12-5-17 I . . BAK f CHARO Patient: ARUNDEL, ALICIA Date of Accident: Chiropractic Re-Evaluat Complaints: NECK PAIN, MIDBACK PAIN WITH INTERMITTENT RADIATION/REFERRAL INTO LEFT UPPER EXTREMITY, LEFT SHOULDER PAIN, LEFT EL8OW PAIN Pt reports continued improvement in neckand back painsymptoms withdecrease upper in left pain