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MARIA RODRIGUEZ
MEDICAL RECORDS
UEZ, MARIA (id #293, dob: 12/08/1970)
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ADVANCED SPINE AND PAIN SPECIALISTS PLLC
1485 FM 1960 Bypass Rd. East Suite 260
JUMBLE, TX 77338-3965
Phone: wb) 955-4601, Fax: (281) 605-6804
Date: 03/02/2020
RE: Maria Rodriguez, DOB: 12/08/1970,
PT ID #293
Dear Townsen Memorial Clinics Humble,
| would like to thank you for refe
of Transit lon of Care Encounte tring Maria Rodriguez to our practice for consultation and evaluation
r
neck pain, Motor Vehicle Accident, low back
pain
Referred by Dr. Raymond Schiitt (Townsen)
, on 03/02/2020. | have enclosed a copy of
‘ion for your records. Once again, thank you the
patient. for ai owing me to Participate in the careoffice
ofthis
fi
Sincerely,
Hectronicaliy Signed by: ANDREW
M. KHOURY, MD
:vs3
ee,
og HD
Encounter Reason/Date
Transition of Care Encounter
neck pain, Motor Vehicle Accident, low back
pain
Referred by ly Dr. Raymond Schlitt (Townsen
03/0: )
~ 01:15PM - Towsen Humble Clinic
Proscems:
Reviewed Problems
© Hypercholesterolemia
AuERGies:
Reviewed Allergies
NKDA
Mepicanons:
Patient take: S & cholesterol medication but does
not remember
the neme
ADVANCED SPINE AND PAIN SPECIALISTS PLLC
Redriguez, Maria (ID: 293), DOB: 12/08/1970
=
sid@ effects.
leducated and strongly encouraged the patient to initiate
and maintain healthy {i
changes, including daily aerobic activity such as walking, healthy diet choices and weight
maintenance. | also disc ‘ussed the importance of sleep,si ieep
healthy sleep/wake c: hygiene, and maintaining a
i
Chart review includ! ling diagnostic testing and results, care Plan
and available med icalvinterventional o; ptions. | discussed medic discussed including diagnosis
risks, benefits and choices. All questio! ns were ations including side effects,
understood the nature and contents of the
answered and patient appeared to have
di: iscussion.
Retumto Office
None recorded
ADVANCED SPINE AND PAIN SPECIALISTS PLLC
Rodriguez Maria (1D:293), DOB: 12/08/1970
Faway History:
Reviewed Family History
Father - Diabetes mellitus
~ Hypercholesterolemia
Sociat History:
Reviewed Social History
Tobacco Smoking Status: Never smoker
Most Recent Tobacco Use Screening: 03/02/2020
Alcohol ke: None
iiclt drugs: No
Education: 12
Uve alone or with others?: with others
Suraica, History
Reviewed Surgical History
Appmona History
None recorded
History oF Present Liness:
Pain Management L-spine
Reported by patient.
Location: pain is not radiating
Quality: s!
Severity: current pak level 1/10; worst pain 1/10
Ouration: inte:
OnseyTiming: Sudden; actuai date: (10/17/19)
Context: MVA
Alleviatit Factors: light exercise
Aggrava Factors: cannot identify
Associated Symp! toms: no weakness; no numbness; no bladd
compromise er compromise; no bowel
Radiation: no radiation
Prior Imaging: MRI (cervical and lumbar MRI
Prior EMG: none
reviewed)
Previous Surgery: none
Previous injections: none
Previous PT: helped significantly
Notes:
Has been parti icicipating in PT weekly and doing
exercises at home since November
Significant relief. with
Revew or Systeus:
Patient reports vision change (Blurred
diseases injury. She rep. orts back pain and Vision ) but reports no dry eyes, No irritation, and no
weakness, no arthral igias/joint pain, no swe! Hing neck in but re rts No muscle aches, no muscle eye
osteoporosis, and no in extre! S, NO difficulty walki
fractures. reports no fever,no night Sweats, no significa: ng, no cra S,
significant weight loss, no exercise | intoleranc int weight g:
hearing and no ear pain. She repo: e, no chilis , and no malaise. She rep. jorts no diffi
rts no frequent nosebi
problems. She rey rts No sore throat,no bleeding gums, leeds, no nose problems, and no sinus
No oral abnormal no Snot} ring,no dry mouth,no mouth ulcers
Ss, Mo teeth problems, no ring! in the ears, and no sinusitis. She reportsno ,
chest pain, no arm pain on exe!
no shortness of breath
when down, no palpitations, no known heart murmur, ai when waiking, no shortness of breath
cough, no wheezing, no shortnes: S of breath, no coug! ind no ankle Swelling. She reportsno
no abdominal pain,no nausea, RO Vol up blood, and no sleep apnea. She reports
vomiting blood, no dyspepsia, and no GER . No consti; ion, normal appetite, no diarrhea, not
hematuria, and no Increased 'D. She reports no Incontinence, no difficulty urinating,no
freq:
laceration. no nor-healing areas. no chanaes in hairnalls, normal mole, no jaundice, no rashes,no
y. She reports no ab:
ne psorlasis.no change in skin color. and
ADVANCED SPINE AND PAIN SPECIALISTS PLLC
Rodriguez, Maria (ID: 293), DOB: 12/08/1970
%
No breast lump. She rey ports no loss of consciousness, no weakness, no numbnéss, no seizures, no
dizziness, no migraines, no headaches, no tremor, no gait dysfunction, and no aralysis. She reports
no de sion, no sleep disturbances, feeling safe in a relationship, no alcoho!
hailuci nations, no suicidal thoughts, no mood swings, no memory loss, no agitationabuse, no anxiety,no
no deliriuShe m. reports no , no dementia, and
jue. She rey ports
no swollen glands, no bruising, no excessive
bleeding, no ane: and no phlebitis. She reports no runny nose, no sinus pressure, no itching,no
hives, and no frequent sneez i
Prysical Exan
Patient is a 49-year-old female.
Coresiagionel: Griented to person, place, and time
and well-developed, well-nourished, and in no
HENT:
Head: Normocephalic and atreumatic.
Eyes: Conjunctivae and EOM are normal.
Neck: Neck supple, trachea midline
Cardiovascular: Normal rats 2nd regular rhythm.
Abdomine|: Soft, NT. ND
MSK: Grossly normal
Neuro: No focal deficits
‘Skin: Skin is warm and dry.
Psychiatric: Mood, memory, a! a and judgment normal.
Nursing note and vitais revie
Procepure Documen anon
None recorded
ASSESSMENT/PLAN_
Ms. Maria Rodriguez is a pleasant 49
back pain following MVA. History, imag! ar-old female who presents for evaluation of ne k and low
reports significant improvement since the and phys! ical findings are consistent with °
continue therapy and may RTC as neede accident with PT and exercises at home. Advised to
d if pain worsens and may consider
for injection then.
1. Neck pain
M54.2: Cervicalgia
2. Cervical 5
M47.812: Speondyl
indytosis without mye!
osis without myelopathy
hy
or radiculopathy, cervical region
* seo ration of ce: rvical intervertebral disc
Other cervica! ! disc degeneration, unspecified cervi
cal region
4. Low back pain
MS54.5: Low back pain
5. Degeneration of lumber intervertebr
M5136: Other inter al disc
vertebral disc degeneration, lumbar
region
Discussion Netes
The Pain condition that the patie:ent suffers
mult itidisciplinary approach that invo! from is most often best treated with
deconditioning and wors: ‘ening of the pain Ss an increase in Physical activity to preventa
informal) to address the comorbid psychological cycle,ps ychoio. gical counseling (formal
and/o
effects of pain. This will often inwolve r
ant
judicious use of pain medications a
ind ssinterventional
. pain medi licine strategies to jower the
h erson's pain so that t!
la: sting pain reductions. rticip: ate in the physical act
f the multidisci that will produce long-
is to return the patient to a higher level of overallplinary approac! to pain medicine e:
of dally living. function and res! itoration of their activities id
This visit included dis¢ ussions regarding
diagnosis, prognosis, possible medic:
a.
intervertional oj tions, using only one physicia al, surgical and
only as directe bi ringing in medicationto pain for n pain management, taking
medications
c! linic for a pill count, medicati ion risks and
ADVANCED SPINE AND PAIN SPECIALISTS PLLC
Rodriguez, Maria (ID: 293), DOB: 1240811970
From Alliance MRI Lake Houston 1.281.476.6459 Wed Dec 18 14:46:42 2019 CST Page 1 of 2
~-I
A S&S
ALLIANCE
RODRIGUEZ, MARIA EXAM DATE: 12/17/2018 12:53 PM
12/08/1870 ‘Schiitt, Ray
30106863 MRi CERVICAL
W/O
ACCH: 411438 SEUAGE: Fi49
MRI CERVICAL
WO
EXAM: MRI cervical spine without contrast.
REASON FOR EXAM: Neck pain.
COMPARISON: None.
TECHNIQUE: Muitiplanar, multisequence MRI of the cervical spine without contrast.
FINDINGS:
There is no cervical spine fracture. There is mild reversal of the usual cervical lordosis. The cervical
Spinal cord is normal in caliber and signal The cervicomed
junction
ullaris normal.
y The prevertebral
soft tissues are normal ‘There is an intraosseous hemangiomm in the T2 vericbral body.
Findings by evel:
C2-C3: There is no disc hemiation There is no central canal or neural foraminal stenosis.
C3-C4: There is a broad-based posterior central disc herniation measuring 1 mm
AP. P, Which flattens the
anterior aspect of the thecal sac. There is no central canal or neural foraminal stenosis.
C4-CS: There is a broad-based posterior central disc herniation measuring 1.5 mm AP and
containing
an annolr tear, which suggests an acute injury. This disc hemiation flattens the anterior
aspect of the
spinal cord. There is also moderate right neural framinal stenosis. ‘There js no central
canal stenosis,
C5-C6: There is a broad-based posterior central disc herniation mea1.5 sur mm AP ing
and containing
an annular tear, which suggests an acute injury. This disc hemiation flatiens the anterior aspect of
the
‘thecal sac. There is also moderate right neural foraminal stenosis. ‘There is no central
canal stenosis.
C6-C7: There is a broad-based posterior central disc hemiation measuring 1.5 mm AP, which flattens
the anterior aspect of the thecal sac. There is no central canal or neural fbraminal stenosis,
page
1 of 2
From Alliance MRI Lake Houston 1.281.476.6459 Wed Dec 18 14:50:46 2019 CST Page 2 of 2
AL
AW
LIANCE
2, MARIA EXAM DATE: 12/47/2019 11:50 AM
12/08/1970
MIRN: 30106863
PHYSICIAN: Schiitt, Ray
EXAM: MRI LUMBAR W/O
111439 SEXVAGE: Fi49
MRI LUMBAR
WO
LS-S1: There 3s no disc herniation There is no central canal or
neural foraminal stenosis.
IMPRESSION:
1. At L2-L3, there is a diffisse disc hemiation measuring up
t0 2 mm, which flatens the anterior aspect
of the thecal sac. ‘There are also right anterior and left anterio
r annular tears, which suggest an acute
injury. There is also a superimposed broad- based left neural foraminadisc inc: beeiies
l measuring 4 total
of 4 mm and contai an nin
anmular gtear, which sugganes acutets
injury. ‘This disc hemiatresults
ionin
mid to moderate left neural framinal stenosis and could
impinge the left L2 exiting nerve root.
2s AtL3-L4, there is a broad-based left
neural foraminal disc bemiation measuring 3.5 mm
Cont anai
annular and
ni tear,
ng which Suggests an acute injury. This disc hemiation
neural foraminal stenosis and could impinge the left results in moderate left
L3 exiting nerve root.
3, AtLA there isLSa broad,-based left neural framinal disc ‘hemiation measuring
contai 2 mm and
an anmul
niarng tear, Which sugg an es
acutets
injury. ‘This disc hemiation results in mild left neural
foraminal stenosis.
4. There is no lumbar spine fracture.
Fiectronically Signed By: Tsai, Jamie MD, Board Certifed by The American Baard
of Radiology
Signed On: 12/18/2019 2:50:33 PM
page
2 of 2
Physical Medicine & Rehabilitation
25404 Highway 59 N Suite 102
Porter, Texas 77365
Phone: (281) 354-4000 Fax: (281) 354-8128
INITIAL EVALUATION
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/28/2019
The above-captioned patient was seen today for the purpose of initial consultation, examination and evaluation
of injuries sustained in an automobile collision that occurred on 10/07/2019.
DETAILS OF COLLISION AND PATIENT HISTORY
Ms. Rodriguez provided the following information regarding the particulars of the incident.
The patient presented for evaluation and treatment for injuries resulting from a rear impact MVA> She reports
that she was transported to the ER by ambulance where a CT was taken. The following day she was evaluated
by her physician where x-rays were taken, and medication prescribed. The weather was clear, and the visibility
on the road was good. Ms. Rodriguez reports being a seatbelt-restrained driver. Her vehicle was struck on the
left rear by another vehicle. She did not see the collision coming. She was completely unprepared for the impact
with her head turned to the left. The patient struck the seatback. Her car was equipped with headrests. She
Teports that her vehicle sustained moderate damage in the collision. Immediately following the collision, Ms.
Rodriguez experienced headaches and neck pain. She reports being dazed. The patient's head was injured.
Following the collision, she was taken to Herman Memorial by ambulance. The following tests were done at the
hospital: CT-Scan. For treatment of injuries sustained in this collision prior to entering this office, Ms.
Rodriguez saw another doctor. The patient reports improvement in her condition so far but continues
to have
symptoms. Ms. Rodriguez reports losing time from work as a result of this collision. She reports being able to
perform physical work activities at this time. Since the collision the patient has had problems with loss
of sexual
drive, lying down, restful sleeping, insomnia, and nervousness. The patient has difficulty going
to sleep as a
result of the collision. She wakes up in the middle of the night it because of pain. The patient reports
having no
prior sleep problems.
SYMPTOMS
The patient reports the following complaints.
NECK PAIN
This symptom came on immediately. It is progressively getting better. The intensity of this complaint is mild-
moderate. The frequency of this complaint is intermittent or occurs up to 25% of the time. On a scale from 0 to
10, with 10 being the highest possible level of pain, patient graded the pain as 3. Patient describes the
feeling
associated with this complaint as spasmodic. Located on the both sides. It is aggravated in the morning
and is
relieved in the afternoon. Brought on by bending back, bending to the left, bending to the right, twisting
left,
twisting right, coughing, sneezing, standing, sitting, cold, and lying down. Relieved by bending forward,
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/28/2019
straining, lifting, heat, resting, and medications.
LEFT SHOULDER BLADE PAIN
This symptom came on gradually. It has not changed since it started. The intensity of this complaint is slight;
meaning it interferes with activity. The frequency of this complaint is intermittent or occurs up to 25% of the
time. On a scale from 0 to 10, with 10 being the highest possible level of pain, patient graded the pain as 2.
Patient describes the feeling associated with this complaint as burning. Located on the left side. It appears in the
morning. Brought on by twisting left, twisting right, standing, sitting, and cold. Relieved by bending forward,
bending back, bending to the left, bending to the right, coughing, sneezing, straining, lifting, heat. resting, lying
down, and medications.
LOW BACK PAIN
This symptom came on gradually. It has not changed since it started. The intensity of this complaint
is slight;
meaning it interferes with activity. The frequency of this complaint is intermittent or occurs
up to 25% of the
time. On a scale from 0 to 10, with 10 being the highest possible level of pain, patient graded
the pain as 2.
Patient describes the feeling associated with this complaint as spasmodic. Located on
the both sides. It is
relicved in the morning and reappears in the afternoon. Brot ught on by bending forward, bending
back, sitting,
and cold. Relieved by bending to the left, bending to the ri; ight, twisting left, twisting
right, coughing, sneezing,
straining, standing, lifting, heat, resting, lying down, and medications.
PAST MEDICAL HISTORY
High cholesterol and Osteoporosis.
PAST FAMILY HISTORY
+ High cholesterol (father).
+ Cancer (aunt).
+ Depression (cousin).
» Diabetes (father).
CURRENT MEDICATIONS
+ Anti-inflammatories.
SOCIAL HISTORY
Ms. Rodriguez is married and has 3 children. She reports the use of caffeine
. The patient states that she never
smoked.
Pp LYSICAL [ATION
The patient's vital signs are:
+ Blood Pressure: 115/80 mmHg (left arm in sitting position)
* Pulse: 57 BPM
Page
2 of 6
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/28/2019
* Temperature: 97°F
General/Constitutional: Ms. Rodriguez is 48 years old. She has a normal build.
Ambulation: Normal.
Gait: Normal.
Posture: Normal.
MUSCULOSKELETAL EXAMINATION
CERVICAL SPINE
There was tenderness to digital palpation and muscle tension on both sides of the cervical spine. There was
muscle hypertonicity present on both sides of the cervical spine. There was muscle spasm present on both sides
of the cervical spine. Digital palpation for trigger points was positive in the cervical area. Multiple active trigger
points are stimulated with moderate digital pressure to the cervical muscles and are associated with consistent
referred pain. Trigger points are located on paracervical bilateral paracervical bilateral. Subluxations are noted
at the following levels: C4 and C5. Reports concomitant headaches. Radicular symptoms into left shoulder and
upper arm.
THORACIC SPINE
There was tendemess to digital palpation and muscle tension on the left side of the thoracic spine. There was
muscle hypertonicity present on the left side of the thoracic spine. Digital palpation for trigger points was
Positive in the thoracic area. Multiple active trigger points are stimulated with moderate digital pressure to the
thoracic muscles and are associated with consistent referred pain. Trigger points are located on parathorac
ic
bilateral. Subluxations are noted at the following levels: T5 and T6.
LUMBAR SPINE
There was tenderness to digital palpation and muscle tension on both sides of the lumbar spine.
There was
muscle hypertonicity present on both sides of the lumbar spine. Digital palpation for trigger points
was positive
in the lumbar area. Multiple active trigger points are stimulated with moderate digital pressure
to the lumbar
muscles and are associated with consistent referred pain. Trigger points are located on paralumba
r bilateral.
Subluxations are noted at the following levels: L5 and sacrum.
RANGE OF MOTION
+ Cervical Spine: Ranges of motion were moderately reduced. Patient states pain on extension, lateral
bending
bilaterally, and rotation on the left.
+ Thoracic Spine: Ranges of motion were within normal limits.
+ Lumbar Spine: Ranges of motion were within normal limits.
MANUAL MUSCLE TESTING
Grade 5 is normal, grade 4 is good, grade 3 is fair, grade 2 is poor, grade 1 is trace, and grade 0 is zero.
CERVICAL
Page
3 of 6
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/28/2019
General weakness in all cervical muscles.
LUMBAR
Lumbar muscles were found to be normal.
ORTHOPEDIC SIGNS
CERVICAL TESTS
Cervical Compression Test: Vertical Cervical Compression was positive and elicited pain in the cervical
spine. Manual downward compression is applied by the examiner to the top of the patient's head. A positive
result of spinal pain may suggest ligamentous instability and/or osseous pathology in the spine frequently seen
in sprain and strain injuries.
Maximal Cervical Compression Test: Maximum Cervical Rotary Compression with the patient passively
rotating, laterally bending and extending the head, while the Doctor waits and watches for the patient's
response, was positive on both sides. A positive result of spinal pain or radicular pain on the opposite side of
rotation may suggest muscular strain in the cervical spine.
Foraminal Compression Test: Cervical Foraminal compression test of the cervical spine was positive on both
sides. A positive sign of spinal pain as a result of downward compression and applied rotation of the patient's
head, may suggest foraminal encroachment.
Shoulder Depression Maneuver: Positive on both sides. Flexion of the head away from affected area while
compressing patient's shoulder to point of pain. A positive sign may indicate adhesions of the nerve roots of
dural sheath.
Soto Hall Test: The Soto Hall test was positive for pain at the cervico thoracic region level. A positive test of
localized non-radiating pain in the cervico dorsal spine during passive flexion may suggest likely ligamentous
sprain in the posterior spinal segments or possible vertebral fracture.
LUMBAR TESTS
Bechterew's Sitting Test: Bechterew’s Test (seated straight-leg raising) was negative on both sides. A positive
sign of low back pain during seated leg extension may suggest lumbosacral injury.
Kemp's Test: Kemp's test was positive on both sides. A positive result of localized non-radiating low back pain
as the patient extends and rotates the trunk may suggest vertebral facet or pericapsular inflammation.
Valsalva's Test: Negative. Positive sign is onset or increase of pain reported when the patient was asked to
hold their breath and bear down increasing intraspinal pressure.
Lasegue's Test: Lasegue's Straight Leg Raise Test was positive on both sides. A positive sign of lower back
pain when the leg is flexed at the hip while in a supine position may suggest lumbar spine dysfunction.
Straight Leg Raising Test: Pain when the leg is lifted on both legs, possibly indicating sciatic neuralgia. The
Page
4 of 6
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/28/2019
Doctor lifts the affected leg to the point of pain; patient flexes the head.
Observation: The patient can walk on heels and toes.
HAND TESTS
Grip Test: Grip strength measurements are observed and recorded after the patient is instructed and
demonstrates ability to perform using a Grip Dynamometer Gauge. Protocols of testing as described in the
AMA's "Guides to the Evaluation of Permanent Impairment", 2000, 5th edition, are incorpora
ted in this
evaluation. The test is measured in "pounds" of compression force.
Grip strength test results are in acceptable and normal limits as set forth by the American
Medical Association's
guidelines. The uniformity of the data collected in this test is a valid indi ication that the patient
has put forth
“maximum voluntary effort".
NEUROLOGICAL EXAMINATION
REFLEXES
The deep tendon reflexes were evaluated and graded using the Wexler
scale. (0 = absent with reinforcement, 1+
= hypoactive, 2+ = normal, 3+ = hyperactive, 4+ = hyperactive with transie
nt clonus, 5+ = hyperactive with
sustained clonus.)
+ The upper and the lower extremities reflexes were tested and found
to be 2+ bilaterally.
X-RAY RESULTS
Brought x rays on disc from another facility for review
DIAGNOSIS
* (M50.02) Cervical Disorder (displaced/annular tear/protrus
ion/deg eneration) WITH Myelopathy C4-C7
* (G54.2) Cervical Root Disorders, not elsewhere classified.
* (S16.1XXA) Strain of muscle, fascia and tendon at neck level,
initial encounter.
+ (S13.4XXA) Sprain of ligaments of cervical spine, initial encoun
ter.
* (G44.319) Acute post-traumatic headache, not intractable.
+ (S39.012A) Strain of muscle, fascia and tendon of lower back, initial
encounter.
+ (S29.019) Strain of muscle Thorax.
* (M99.01) Segmental and Somatic Dysfunction of Cervical Region
.
* (M99.03) Segmental and Somatic Dysfunction of Lumbar Region
.
* (M99.02) Segmental and Somatic Dysfunction of Thoracic Region
.
TREATMENT
Treatment today consisted of the following procedures and therapi
es:
Page 5 of 6
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/28/2019
Evaluation & Management New Patient (99204).
+ Electric Stimulation (G0283).
+ Manual Therapy (Joint Mobilization, Manipulation, Manual Traction, Trigger Point Therapy, Myofascial
Release) (97140).
+ Therapeutic Activities (Dynamic Activities to Restore Mobility, Strength, Balance, Coordination) (97530).
+ Chiropractic Manipulation 3-4 Spinal Regions (98941).
GOALS AND RECOMMENDATIONS
+ Treatment goals are to restore motion, improve strength and function, and reduce pain and swelling through
Therapeutic Exercise and Activities.
+ Chiropractic manipulation to restore proper motion segm\ ent integrity and movement with reduction of pelvic
distortion eliminating Deerfield-Thomson positive findings.
+ Manual therapy increases active pain free ROM and increases extensibility of myofascial tissue.
+ Electric stimulation (interferential current) will be used to promote a fluid shift in the interstitial space of the
muscle and connective tissue as well as to modulate pain reduction in the affected tissues.
* MRI of injured body part if symptoms continue.
PROFESSIONAL OPINION
Due to the nature of the injuries traumatically induced and the reduced function
al capacity manifested as a
result. It is likely that the areas of injury may remain areas of greater risk of future
trouble from aggravation and
trauma which may not have had the same effect prior to the accident.
WORK DISABILITY
No work or excessive physical activity for two weeks. Will re-evaluate
at two weeks.
PROGNOSIS
At this point in time, it is my opinion that the prognosis for Ms. Rodrigu
ez is guarded.
Ray Schlitt, DC
Page 6 of 6
Physical Medicine & Rehabilitation
25404 Highway 59 N Suite 102
Porter, Texas 77365
Phone: (281) 354-4000 Fax: (281) 354-8128
DAILY NOTE
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/29/2019
JECTIVE
The patient complained of the following symptoms today:
+ Neck pain.
+ Left shoulder blade pain.
+ Low back pain.
OBJECTIVE
Examination today revealed the following positive findings:
+ Tendemess is present in the Cervical, Thoracic and Lumbar musculature,
+ Restricted Cervical Range of Motion.
+ Deerfield test was found to be positive today.
+ Fixations at C4, C5, T5, T6, L5, and sacrum.
* Lack of joint mobility.
+ Myospasm of the Cervical, Thoracic and Lumbar paraspinal musculature.
L
* (M50.02) Cervical Disorder (displaced/annular tear/protrusi jion/degeneration) WITH Myelopathy C4-C7
* (G54.2) Cervical Root Disorders, not elsewhere classified.
+ (S16.1XXA) Strain of muscle, fascia and tendon at neck level,
initial encounter.
+ (S13.4XXA) Sprain of ligaments of cervical spine, initial encounter.
+ (G44.319) Acute post-traumatic headache, not intractable.
* (S39.012A) Strain of muscle, fascia and tendon of lower back, initial
encounter.
+ (S29.019) Strain of muscle Thorax.
+ (M99.01) Segmental and Somatic Dysfunction of Cervical Region.
> (M99.03) Segmental and Somatic Dysfunction of Lumbar Region.
+ (M99.02) Segmental and Somatic Dysfunction of Thoracic Region.
G (ME) I iS
+ Treatment goals are to restore motion, improve strength and function,
and reduce pain and swelling through Therapeutic Exercise
and Activities.
+ Chiropractic manipulation to restore Proper motion segment integrit
y and movement with reduction of pelvic distortion eliminat
Deerfield-Thomson positive findings. ing
+ Manual therapy increase active pain free ROM and in creases extensibility
of myofascial tissue.
+ Electric stimulation (interferential current) will be used to Promote
a fluid shift in the interstitial space of the muscle and connective
tissue as well as to modulate pain reduction in the affected ti issues,
+ MRI of injured body part if symptoms continue.
ASSESSMENT
* This patient was noted to have a positive Deerfie! Id test, demonstrating a
left short leg. After the treatment today, the Deerfield test
was found to be normal.
+ Lack of proper joint mobility was resolved with the treatment Protocol today.
+ The patient appeared to tolerate the treatment well today.
PLAN
‘Treatment today consisted of the following procedures and therapies:
PATIENT NAME: i Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/29/2019
+ Electric Stimulation (G0283).
* Manual Therapy (Joint Mobilization, Manipulation, Manual Traction, Trigger Point Therapy, Myofascial Release) (97140).
* Therapeutic Activities (Dynamic Activities to Restore Mobility, Strength, Balance, Coordination) (97530).
* Chiropractic Manipulation 3-4 Spinal Regions (98941).
Ray Schlitt, DC
Page
2 of 2
Physical Medicine & Rehabilitation
25404 Highway 59 N Suite 102
Porter, Texas 77365
Phone: (281) 354-4000 Fax: (281) 354-8128
DAILY NOTE
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/30/2019
SUBJECTIVE
The patient complained of the following symptoms today:
* Neck pain.
+ Left shoulder blade pain.
+ Low back pain.
OBJECTIVE
Examination today revealed the following positive findings:
+ Paraspinal tenderness is found during palpation of the Cervical, Thoracic and Lumbar.
+ Range of Motion of Cervical Spine is restricted.
* A positive Deerfield Test was noted today..
+ Fixations at C4, C5, TS, T6, L5, and sacrum,
+ Lack of joint mobility is noted.
+ Myofascial dysfunction with focal muscle spasm are present in the ‘Thoracic, Lumbar and Cervical paraspinal
soft tissue.
DIAGN
* (MS0.02) Cervical Disorder (displaced/annular tear/protrusion/de legeneration) WITH
Myelopathy C4-C7.
* (G54.2) Cervical Root Disorders, not elsewhere classified,
* (S16.1XXA) Strain of muscle, fascia and tendon at neck level, initial encounter.
+ (S13.4XXA) Sprain of ligaments of cervical spine, initial encounter.
+ (G44.319) Acute post-traumatic headache, not intractable.
+ (S39.012A) Strain of muscle, fascia and tendon of lower back, initial encounter.
+ (S29.019) Strain of muscle Thorax.
* (M99.01) Segmental and Somatic Dysfunction of Cervical Region.
* (M99.03) Segmental and Somatic Dysfunction of Lumbar Region.
+ (M99.02) Segmental and Somatic Dysfunction of Thoracic Region.
AND MMI ATION:
+ Treatment goals are to restore motion, improve strength and function, and reduce
pain and swelling through Therapeutic Exercise
and Activities.
+ Chiropractic manipulation to restore Proper motion segment integrity
and movement with reduction of pelvic distortion eliminating
Deerfield-Thomson positive findings.
+ Manual therapy increase active pain free ROM and increases extensibility of myofascial
tissue.
+ Electric stimulation (interferential current) will be used to promote a fluid shift
in the interstitial space of the muscle and connective
tissue as well as to modulate pain reduction in the affected ti ‘issues.
+ MRI of injured body part if symptoms continue.
ASSESSMENT
+ This patient was noted to have a Positive Deerfield test, demonstrating a left short leg. After the
treatment today, the Deerfield test
was found to be normal.
« Lack of proper joint mobility was resolved with the treatment protocol today.
+ The patient appeared to tolerate the treatment well today.
PLAN
Treatment today consisted of the following procedures and therapies:
PATIENT NAME: Rodri Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/30/2019
+ Electric Stimulation (G0283).
* Manual Therapy (Joint Mobilization, Manipulation, Manual Traction, Trigger Point Therapy, Myofascial Release) (97140).
+ Therapeutic Activities (Dynamic Activities to Restore Mobility, Strength, Balance, Coordination) (97530).
+ Chiropractic Manipulation 3-4 Spinal Regions (98941).
Ray Schlitt, DC
Page
2 of 2
Physical Medicine & Rehabilitation
25404 Highway 59 N Suite 102
Porter, Texas 77365
Phone: (281) 354-4000 Fax: (281) 354-8128
AILY Ni
PATIENT NAME: Rodriguez, Maria
DATE OF INJURY: 10/07/2019
DATE OF SERVICE: 10/31/2019
CTIVE
The patient complained of the following symptoms today:
« Neck pain.
+ Left shoulder blade pain.
+ Low back pain.
OBJECTIVE
Examination today revealed the following positive findings:
+ Tenderness is present in the Cervical, Thoracic and Lumbar musculature.
+ Restricted Cervical Range of Motion.
+ Asymmetrical leg lengths are noted upon completion of the Deerfield test...
+ Fixations at C4, C5, TS, T6, LS, and sacrum.
+ It was noted at the affected body part today, that there are joint mobility issues...
+ Myospasm of the Cervical, Thoracic and Lumbar paraspinal musculature.
DIA‘ S!
* (MS0.02) Cervical Disorder (displaced/annular tear/protrusion/degeneration) WITH Myelopathy
C4-C7
+ (G54.2) Cervical Root Disorders, not elsewhere classified.
+ (S16.1XXA) Strain of muscle, fascia and tendon at neck level, initial encounter.
+ (S13.4XXA) Sprain of ligaments of cervical spine, initial encounter.
* (G44.319) Acute post-traumatic headache, not intractable.
* (S39.012A) Strain of muscle, fascia and tendon of lower back, initial encounter.
+ (S29.019) Strain of muscle Thorax.
* (M99.01) Segmental and Somatic Dysfunction of Cervical Region.
* (M99.03) Segmental and Somatic Dysfunction of Lumbar Region.
* (M99.02) Segmental and Somatic Dysfunction of Thoracic Region.
G S AND REt TION:
* Treatment goals are to restore motion, improve strength and function, and reduce
pain and swelling through Therapeutic Exercise
and Activities.
+ Chiropractic manipulation to restore Proper motion segment integrity and movement with reduction
of pelvic distortion eliminating
Deerfield-Thomson positive findings.
+ Manual therapy increase active pain free ROM and increases extensibility of myofascial
Preview
MARIA RODRIGUEZ MEDICAL RECORDS UEZ, MARIA (id #293, dob: 12/08/1970) This fax may contain sensitive and confidential personal health informati on that is being sert for the sole use of the intended recipient. Unintended recip’ ients are directed to securel; ly destroy any materials received. You are hereby notified that the unauthoriz. ed disclosure personal health informationis prohibited. To the extent patient i or other unlawful use of this fax or a 42 CFR Part 2, this regulation prohibits unauthorized dis! closure of thesetionreco!cor tained In this fax is subject to if you received this fax in error, please visit www.athenahealt confirm that the information will be destro: ye id. If you do not h.comyNotMyFax to notify the sender and 8436 to have irternet access, please call 1-888-482. the sender and confirm thatt! he infor rmation will and cooperation. [1D:6396-H-19723] be destroyed. Thank you for your attention ADVANCED SPINE AND PAIN SPECIALISTS PLLC 1485 FM 1960 Bypass Rd. East Suite 260 JUMBLE, TX 77338-3965 Phone: wb) 955-4601, Fax: (281) 605-6804 Date: 03/02/2020 RE: Maria Rodriguez, DOB: 12/08/1970, PT ID #293 Dear Townsen Memorial Clinics Humble, | would like to thank you for refe of Transit lon of Care Encounte tring Maria Rodriguez to our practice for consultation and evaluation r neck pain, Motor Vehicle Accident, low back pain Referred by Dr. Raymond Schiitt (Townsen) , on 03/02/2020. | have enclosed a copy of ‘ion for your records. Once again, thank you the patient. for ai owing me to Participate in the careoffice ofthis fi Sincerely, Hectronicaliy Signed by: ANDREW M. KHOURY, MD :vs3 ee, og HD Encounter Reason/Date Transition of Care Encounter neck pain, Motor Vehicle Accident, low back pain Referred by ly Dr. Raymond Schlitt (Townsen 03/0: ) ~ 01:15PM - Towsen Humble Clinic Proscems: Reviewed Problems © Hypercholesterolemia AuERGies: Reviewed Allergies NKDA Mepicanons: Patient take: S & cholesterol medication but does not remember the neme ADVANCED SPINE AND PAIN SPECIALISTS PLLC Redriguez, Maria (ID: 293), DOB: 12/08/1970 = sid@ effects. leducated and strongly encouraged the patient to initiate and maintain healthy {i changes, including daily aerobic activity such as walking, healthy diet choices and weight maintenance. | also disc ‘ussed the importance of sleep,si ieep healthy sleep/wake c: hygiene, and maintaining a i Chart review includ! ling diagnostic testing and results, care Plan and available med icalvinterventional o; ptions. | discussed medic discussed including diagnosis risks, benefits and choices. All questio! ns were ations including side effects, understood the nature and contents of the answered and patient appeared to have di: iscussion. Retumto Office None recorded ADVANCED SPINE AND PAIN SPECIALISTS PLLC Rodriguez Maria (1D:293), DOB: 12/08/1970 Faway History: Reviewed Family History Father - Diabetes mellitus ~ Hypercholesterolemia Sociat History: Reviewed Social History Tobacco Smoking Status: Never smoker Most Recent Tobacco Use Screening: 03/02/2020 Alcohol ke: None iiclt drugs: No Education: 12 Uve alone or with others?: with others Suraica, History Reviewed Surgical History Appmona History None recorded History oF Present Liness: Pain Management L-spine Reported by patient. Location: pain is not radiating Quality: s! Severity: current pak level 1/10; worst pain 1/10 Ouration: inte: OnseyTiming: Sudden; actuai date: (10/17/19) Context: MVA Alleviatit Factors: light exercise Aggrava Factors: cannot identify Associated Symp! toms: no weakness; no numbness; no bladd compromise er compromise; no bowel Radiation: no radiation Prior Imaging: MRI (cervical and lumbar MRI Prior EMG: none reviewed) Previous Surgery: none Previous injections: none Previous PT: helped significantly Notes: Has been parti icicipating in PT weekly and doing exercises at home since November Significant relief. with Revew or Systeus: Patient reports vision change (Blurred diseases injury. She rep. orts back pain and Vision ) but reports no dry eyes, No irritation, and no weakness, no arthral igias/joint pain, no swe! Hing neck in but re rts No muscle aches, no muscle eye osteoporosis, and no in extre! S, NO difficulty walki fractures. reports no fever,no night Sweats, no significa: ng, no cra S, significant weight loss, no exercise | intoleranc int weight g: hearing and no ear pain. She repo: e, no chilis , and no malaise. She rep. jorts no diffi rts no frequent nosebi problems. She rey rts No sore throat,no bleeding gums, leeds, no nose problems, and no sinus No oral abnormal no Snot} ring,no dry mouth,no mouth ulcers Ss, Mo teeth problems, no ring! in the ears, and no sinusitis. She reportsno , chest pain, no arm pain on exe! no shortness of breath when down, no palpitations, no known heart murmur, ai when waiking, no shortness of breath cough, no wheezing, no shortnes: S of breath, no coug! ind no ankle Swelling. She reportsno no abdominal pain,no nausea, RO Vol up blood, and no sleep apnea. She reports vomiting blood, no dyspepsia, and no GER . No consti; ion, normal appetite, no diarrhea, not hematuria, and no Increased 'D. She reports no Incontinence, no difficulty urinating,no freq: laceration. no nor-healing areas. no chanaes in hairnalls, normal mole, no jaundice, no rashes,no y. She reports no ab: ne psorlasis.no change in skin color. and ADVANCED SPINE AND PAIN SPECIALISTS PLLC Rodriguez, Maria (ID: 293), DOB: 12/08/1970 % No breast lump. She rey ports no loss of consciousness, no weakness, no numbnéss, no seizures, no dizziness, no migraines, no headaches, no tremor, no gait dysfunction, and no aralysis. She reports no de sion, no sleep disturbances, feeling safe in a relationship, no alcoho! hailuci nations, no suicidal thoughts, no mood swings, no memory loss, no agitationabuse, no anxiety,no no deliriuShe m. reports no , no dementia, and jue. She rey ports no swollen glands, no bruising, no excessive bleeding, no ane: and no phlebitis. She reports no runny nose, no sinus pressure, no itching,no hives, and no frequent sneez i Prysical Exan Patient is a 49-year-old female. Coresiagionel: Griented to person, place, and time and well-developed, well-nourished, and in no HENT: Head: Normocephalic and atreumatic. Eyes: Conjunctivae and EOM are normal. Neck: Neck supple, trachea midline Cardiovascular: Normal rats 2nd regular rhythm. Abdomine|: Soft, NT. ND MSK: Grossly normal Neuro: No focal deficits ‘Skin: Skin is warm and dry. Psychiatric: Mood, memory, a! a and judgment normal. Nursing note and vitais revie Procepure Documen anon None recorded ASSESSMENT/PLAN_ Ms. Maria Rodriguez is a pleasant 49 back pain following MVA. History, imag! ar-old female who presents for evaluation of ne k and low reports significant improvement since the and phys! ical findings are consistent with ° continue therapy and may RTC as neede accident with PT and exercises at home. Advised to d if pain worsens and may consider for injection then. 1. Neck pain M54.2: Cervicalgia 2. Cervical 5 M47.812: Speondyl indytosis without mye! osis without myelopathy hy or radiculopathy, cervical region * seo ration of ce: rvical intervertebral disc Other cervica! ! disc degeneration, unspecified cervi cal region 4. Low back pain MS54.5: Low back pain 5. Degeneration of lumber intervertebr M5136: Other inter al disc vertebral disc degeneration, lumbar region Discussion Netes The Pain condition that the patie:ent suffers mult itidisciplinary approach that invo! from is most often best treated with deconditioning and wors: ‘ening of the pain Ss an increase in Physical activity to preventa informal) to address the comorbid psychological cycle,ps ychoio. gical counseling (formal and/o effects of pain. This will often inwolve r ant judicious use of pain medications a ind ssinterventional . pain medi licine strategies to jower the h erson's pain so that t! la: sting pain reductions. rticip: ate in the physical act f the multidisci that will produce long- is to return the patient to a higher level of overallplinary approac! to pain medicine e: of dally living. function and res! itoration of their activities id This visit included dis¢ ussions regarding diagnosis, prognosis, possible medic: a. intervertional oj tions, using only one physicia al, surgical and only as directe bi ringing in medicationto pain for n pain management, taking medications c! linic for a pill count, medicati ion risks and ADVANCED SPINE AND PAIN SPECIALISTS PLLC Rodriguez, Maria (ID: 293), DOB: 1240811970 From Alliance MRI Lake Houston 1.281.476.6459 Wed Dec 18 14:46:42 2019 CST Page 1 of 2 ~-I A S&S ALLIANCE RODRIGUEZ, MARIA EXAM DATE: 12/17/2018 12:53 PM 12/08/1870 ‘Schiitt, Ray 30106863 MRi CERVICAL W/O ACCH: 411438 SEUAGE: Fi49 MRI CERVICAL WO EXAM: MRI cervical spine without contrast. REASON FOR EXAM: Neck pain. COMPARISON: None. TECHNIQUE: Muitiplanar, multisequence MRI of the cervical spine without contrast. FINDINGS: There is no cervical spine fracture. There is mild reversal of the usual cervical lordosis. The cervical Spinal cord is normal in caliber and signal The cervicomed junction ullaris normal. y The prevertebral soft tissues are normal ‘There is an intraosseous hemangiomm in the T2 vericbral body. Findings by evel: C2-C3: There is no disc hemiation There is no central canal or neural foraminal stenosis. C3-C4: There is a broad-based posterior central disc herniation measuring 1 mm AP. P, Which flattens the anterior aspect of the thecal sac. There is no central canal or neural foraminal stenosis. C4-CS: There is a broad-based posterior central disc herniation measuring 1.5 mm AP and containing an annolr tear, which suggests an acute injury. This disc hemiation flattens the anterior aspect of the spinal cord. There is also moderate right neural framinal stenosis. ‘There js no central canal stenosis, C5-C6: There is a broad-based posterior central disc herniation mea1.5 sur mm AP ing and containing an annular tear, which suggests an acute injury. This disc hemiation flatiens the anterior aspect of the ‘thecal sac. There is also moderate right neural foraminal stenosis. ‘There is no central canal stenosis. C6-C7: There is a broad-based posterior central disc hemiation measuring 1.5 mm AP, which flattens the anterior aspect of the thecal sac. There is no central canal or neural fbraminal stenosis, page 1 of 2 From Alliance MRI Lake Houston 1.281.476.6459 Wed Dec 18 14:50:46 2019 CST Page 2 of 2 AL AW LIANCE 2, MARIA EXAM DATE: 12/47/2019 11:50 AM 12/08/1970 MIRN: 30106863 PHYSICIAN: Schiitt, Ray EXAM: MRI LUMBAR W/O 111439 SEXVAGE: Fi49 MRI LUMBAR WO LS-S1: There 3s no disc herniation There is no central canal or neural foraminal stenosis. IMPRESSION: 1. At L2-L3, there is a diffisse disc hemiation measuring up t0 2 mm, which flatens the anterior aspect of the thecal sac. ‘There are also right anterior and left anterio r annular tears, which suggest an acute injury. There is also a superimposed broad- based left neural foraminadisc inc: beeiies l measuring 4 total of 4 mm and contai an nin anmular gtear, which sugganes acutets injury. ‘This disc hemiatresults ionin mid to moderate left neural framinal stenosis and could impinge the left L2 exiting nerve root. 2s AtL3-L4, there is a broad-based left neural foraminal disc bemiation measuring 3.5 mm Cont anai annular and ni tear, ng which Suggests an acute injury. This disc hemiation neural foraminal stenosis and could impinge the left results in moderate left L3 exiting nerve root. 3, AtLA there isLSa broad,-based left neural framinal disc ‘hemiation measuring contai 2 mm and an anmul niarng tear, Which sugg an es acutets injury. ‘This disc hemiation results in mild left neural foraminal stenosis. 4. There is no lumbar spine fracture. Fiectronically Signed By: Tsai, Jamie MD, Board Certifed by The American Baard of Radiology Signed On: 12/18/2019 2:50:33 PM page 2 of 2 Physical Medicine & Rehabilitation 25404 Highway 59 N Suite 102 Porter, Texas 77365 Phone: (281) 354-4000 Fax: (281) 354-8128 INITIAL EVALUATION PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/28/2019 The above-captioned patient was seen today for the purpose of initial consultation, examination and evaluation of injuries sustained in an automobile collision that occurred on 10/07/2019. DETAILS OF COLLISION AND PATIENT HISTORY Ms. Rodriguez provided the following information regarding the particulars of the incident. The patient presented for evaluation and treatment for injuries resulting from a rear impact MVA> She reports that she was transported to the ER by ambulance where a CT was taken. The following day she was evaluated by her physician where x-rays were taken, and medication prescribed. The weather was clear, and the visibility on the road was good. Ms. Rodriguez reports being a seatbelt-restrained driver. Her vehicle was struck on the left rear by another vehicle. She did not see the collision coming. She was completely unprepared for the impact with her head turned to the left. The patient struck the seatback. Her car was equipped with headrests. She Teports that her vehicle sustained moderate damage in the collision. Immediately following the collision, Ms. Rodriguez experienced headaches and neck pain. She reports being dazed. The patient's head was injured. Following the collision, she was taken to Herman Memorial by ambulance. The following tests were done at the hospital: CT-Scan. For treatment of injuries sustained in this collision prior to entering this office, Ms. Rodriguez saw another doctor. The patient reports improvement in her condition so far but continues to have symptoms. Ms. Rodriguez reports losing time from work as a result of this collision. She reports being able to perform physical work activities at this time. Since the collision the patient has had problems with loss of sexual drive, lying down, restful sleeping, insomnia, and nervousness. The patient has difficulty going to sleep as a result of the collision. She wakes up in the middle of the night it because of pain. The patient reports having no prior sleep problems. SYMPTOMS The patient reports the following complaints. NECK PAIN This symptom came on immediately. It is progressively getting better. The intensity of this complaint is mild- moderate. The frequency of this complaint is intermittent or occurs up to 25% of the time. On a scale from 0 to 10, with 10 being the highest possible level of pain, patient graded the pain as 3. Patient describes the feeling associated with this complaint as spasmodic. Located on the both sides. It is aggravated in the morning and is relieved in the afternoon. Brought on by bending back, bending to the left, bending to the right, twisting left, twisting right, coughing, sneezing, standing, sitting, cold, and lying down. Relieved by bending forward, PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/28/2019 straining, lifting, heat, resting, and medications. LEFT SHOULDER BLADE PAIN This symptom came on gradually. It has not changed since it started. The intensity of this complaint is slight; meaning it interferes with activity. The frequency of this complaint is intermittent or occurs up to 25% of the time. On a scale from 0 to 10, with 10 being the highest possible level of pain, patient graded the pain as 2. Patient describes the feeling associated with this complaint as burning. Located on the left side. It appears in the morning. Brought on by twisting left, twisting right, standing, sitting, and cold. Relieved by bending forward, bending back, bending to the left, bending to the right, coughing, sneezing, straining, lifting, heat. resting, lying down, and medications. LOW BACK PAIN This symptom came on gradually. It has not changed since it started. The intensity of this complaint is slight; meaning it interferes with activity. The frequency of this complaint is intermittent or occurs up to 25% of the time. On a scale from 0 to 10, with 10 being the highest possible level of pain, patient graded the pain as 2. Patient describes the feeling associated with this complaint as spasmodic. Located on the both sides. It is relicved in the morning and reappears in the afternoon. Brot ught on by bending forward, bending back, sitting, and cold. Relieved by bending to the left, bending to the ri; ight, twisting left, twisting right, coughing, sneezing, straining, standing, lifting, heat, resting, lying down, and medications. PAST MEDICAL HISTORY High cholesterol and Osteoporosis. PAST FAMILY HISTORY + High cholesterol (father). + Cancer (aunt). + Depression (cousin). » Diabetes (father). CURRENT MEDICATIONS + Anti-inflammatories. SOCIAL HISTORY Ms. Rodriguez is married and has 3 children. She reports the use of caffeine . The patient states that she never smoked. Pp LYSICAL [ATION The patient's vital signs are: + Blood Pressure: 115/80 mmHg (left arm in sitting position) * Pulse: 57 BPM Page 2 of 6 PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/28/2019 * Temperature: 97°F General/Constitutional: Ms. Rodriguez is 48 years old. She has a normal build. Ambulation: Normal. Gait: Normal. Posture: Normal. MUSCULOSKELETAL EXAMINATION CERVICAL SPINE There was tenderness to digital palpation and muscle tension on both sides of the cervical spine. There was muscle hypertonicity present on both sides of the cervical spine. There was muscle spasm present on both sides of the cervical spine. Digital palpation for trigger points was positive in the cervical area. Multiple active trigger points are stimulated with moderate digital pressure to the cervical muscles and are associated with consistent referred pain. Trigger points are located on paracervical bilateral paracervical bilateral. Subluxations are noted at the following levels: C4 and C5. Reports concomitant headaches. Radicular symptoms into left shoulder and upper arm. THORACIC SPINE There was tendemess to digital palpation and muscle tension on the left side of the thoracic spine. There was muscle hypertonicity present on the left side of the thoracic spine. Digital palpation for trigger points was Positive in the thoracic area. Multiple active trigger points are stimulated with moderate digital pressure to the thoracic muscles and are associated with consistent referred pain. Trigger points are located on parathorac ic bilateral. Subluxations are noted at the following levels: T5 and T6. LUMBAR SPINE There was tenderness to digital palpation and muscle tension on both sides of the lumbar spine. There was muscle hypertonicity present on both sides of the lumbar spine. Digital palpation for trigger points was positive in the lumbar area. Multiple active trigger points are stimulated with moderate digital pressure to the lumbar muscles and are associated with consistent referred pain. Trigger points are located on paralumba r bilateral. Subluxations are noted at the following levels: L5 and sacrum. RANGE OF MOTION + Cervical Spine: Ranges of motion were moderately reduced. Patient states pain on extension, lateral bending bilaterally, and rotation on the left. + Thoracic Spine: Ranges of motion were within normal limits. + Lumbar Spine: Ranges of motion were within normal limits. MANUAL MUSCLE TESTING Grade 5 is normal, grade 4 is good, grade 3 is fair, grade 2 is poor, grade 1 is trace, and grade 0 is zero. CERVICAL Page 3 of 6 PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/28/2019 General weakness in all cervical muscles. LUMBAR Lumbar muscles were found to be normal. ORTHOPEDIC SIGNS CERVICAL TESTS Cervical Compression Test: Vertical Cervical Compression was positive and elicited pain in the cervical spine. Manual downward compression is applied by the examiner to the top of the patient's head. A positive result of spinal pain may suggest ligamentous instability and/or osseous pathology in the spine frequently seen in sprain and strain injuries. Maximal Cervical Compression Test: Maximum Cervical Rotary Compression with the patient passively rotating, laterally bending and extending the head, while the Doctor waits and watches for the patient's response, was positive on both sides. A positive result of spinal pain or radicular pain on the opposite side of rotation may suggest muscular strain in the cervical spine. Foraminal Compression Test: Cervical Foraminal compression test of the cervical spine was positive on both sides. A positive sign of spinal pain as a result of downward compression and applied rotation of the patient's head, may suggest foraminal encroachment. Shoulder Depression Maneuver: Positive on both sides. Flexion of the head away from affected area while compressing patient's shoulder to point of pain. A positive sign may indicate adhesions of the nerve roots of dural sheath. Soto Hall Test: The Soto Hall test was positive for pain at the cervico thoracic region level. A positive test of localized non-radiating pain in the cervico dorsal spine during passive flexion may suggest likely ligamentous sprain in the posterior spinal segments or possible vertebral fracture. LUMBAR TESTS Bechterew's Sitting Test: Bechterew’s Test (seated straight-leg raising) was negative on both sides. A positive sign of low back pain during seated leg extension may suggest lumbosacral injury. Kemp's Test: Kemp's test was positive on both sides. A positive result of localized non-radiating low back pain as the patient extends and rotates the trunk may suggest vertebral facet or pericapsular inflammation. Valsalva's Test: Negative. Positive sign is onset or increase of pain reported when the patient was asked to hold their breath and bear down increasing intraspinal pressure. Lasegue's Test: Lasegue's Straight Leg Raise Test was positive on both sides. A positive sign of lower back pain when the leg is flexed at the hip while in a supine position may suggest lumbar spine dysfunction. Straight Leg Raising Test: Pain when the leg is lifted on both legs, possibly indicating sciatic neuralgia. The Page 4 of 6 PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/28/2019 Doctor lifts the affected leg to the point of pain; patient flexes the head. Observation: The patient can walk on heels and toes. HAND TESTS Grip Test: Grip strength measurements are observed and recorded after the patient is instructed and demonstrates ability to perform using a Grip Dynamometer Gauge. Protocols of testing as described in the AMA's "Guides to the Evaluation of Permanent Impairment", 2000, 5th edition, are incorpora ted in this evaluation. The test is measured in "pounds" of compression force. Grip strength test results are in acceptable and normal limits as set forth by the American Medical Association's guidelines. The uniformity of the data collected in this test is a valid indi ication that the patient has put forth “maximum voluntary effort". NEUROLOGICAL EXAMINATION REFLEXES The deep tendon reflexes were evaluated and graded using the Wexler scale. (0 = absent with reinforcement, 1+ = hypoactive, 2+ = normal, 3+ = hyperactive, 4+ = hyperactive with transie nt clonus, 5+ = hyperactive with sustained clonus.) + The upper and the lower extremities reflexes were tested and found to be 2+ bilaterally. X-RAY RESULTS Brought x rays on disc from another facility for review DIAGNOSIS * (M50.02) Cervical Disorder (displaced/annular tear/protrus ion/deg eneration) WITH Myelopathy C4-C7 * (G54.2) Cervical Root Disorders, not elsewhere classified. * (S16.1XXA) Strain of muscle, fascia and tendon at neck level, initial encounter. + (S13.4XXA) Sprain of ligaments of cervical spine, initial encoun ter. * (G44.319) Acute post-traumatic headache, not intractable. + (S39.012A) Strain of muscle, fascia and tendon of lower back, initial encounter. + (S29.019) Strain of muscle Thorax. * (M99.01) Segmental and Somatic Dysfunction of Cervical Region . * (M99.03) Segmental and Somatic Dysfunction of Lumbar Region . * (M99.02) Segmental and Somatic Dysfunction of Thoracic Region . TREATMENT Treatment today consisted of the following procedures and therapi es: Page 5 of 6 PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/28/2019 Evaluation & Management New Patient (99204). + Electric Stimulation (G0283). + Manual Therapy (Joint Mobilization, Manipulation, Manual Traction, Trigger Point Therapy, Myofascial Release) (97140). + Therapeutic Activities (Dynamic Activities to Restore Mobility, Strength, Balance, Coordination) (97530). + Chiropractic Manipulation 3-4 Spinal Regions (98941). GOALS AND RECOMMENDATIONS + Treatment goals are to restore motion, improve strength and function, and reduce pain and swelling through Therapeutic Exercise and Activities. + Chiropractic manipulation to restore proper motion segm\ ent integrity and movement with reduction of pelvic distortion eliminating Deerfield-Thomson positive findings. + Manual therapy increases active pain free ROM and increases extensibility of myofascial tissue. + Electric stimulation (interferential current) will be used to promote a fluid shift in the interstitial space of the muscle and connective tissue as well as to modulate pain reduction in the affected tissues. * MRI of injured body part if symptoms continue. PROFESSIONAL OPINION Due to the nature of the injuries traumatically induced and the reduced function al capacity manifested as a result. It is likely that the areas of injury may remain areas of greater risk of future trouble from aggravation and trauma which may not have had the same effect prior to the accident. WORK DISABILITY No work or excessive physical activity for two weeks. Will re-evaluate at two weeks. PROGNOSIS At this point in time, it is my opinion that the prognosis for Ms. Rodrigu ez is guarded. Ray Schlitt, DC Page 6 of 6 Physical Medicine & Rehabilitation 25404 Highway 59 N Suite 102 Porter, Texas 77365 Phone: (281) 354-4000 Fax: (281) 354-8128 DAILY NOTE PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/29/2019 JECTIVE The patient complained of the following symptoms today: + Neck pain. + Left shoulder blade pain. + Low back pain. OBJECTIVE Examination today revealed the following positive findings: + Tendemess is present in the Cervical, Thoracic and Lumbar musculature, + Restricted Cervical Range of Motion. + Deerfield test was found to be positive today. + Fixations at C4, C5, T5, T6, L5, and sacrum. * Lack of joint mobility. + Myospasm of the Cervical, Thoracic and Lumbar paraspinal musculature. L * (M50.02) Cervical Disorder (displaced/annular tear/protrusi jion/degeneration) WITH Myelopathy C4-C7 * (G54.2) Cervical Root Disorders, not elsewhere classified. + (S16.1XXA) Strain of muscle, fascia and tendon at neck level, initial encounter. + (S13.4XXA) Sprain of ligaments of cervical spine, initial encounter. + (G44.319) Acute post-traumatic headache, not intractable. * (S39.012A) Strain of muscle, fascia and tendon of lower back, initial encounter. + (S29.019) Strain of muscle Thorax. + (M99.01) Segmental and Somatic Dysfunction of Cervical Region. > (M99.03) Segmental and Somatic Dysfunction of Lumbar Region. + (M99.02) Segmental and Somatic Dysfunction of Thoracic Region. G (ME) I iS + Treatment goals are to restore motion, improve strength and function, and reduce pain and swelling through Therapeutic Exercise and Activities. + Chiropractic manipulation to restore Proper motion segment integrit y and movement with reduction of pelvic distortion eliminat Deerfield-Thomson positive findings. ing + Manual therapy increase active pain free ROM and in creases extensibility of myofascial tissue. + Electric stimulation (interferential current) will be used to Promote a fluid shift in the interstitial space of the muscle and connective tissue as well as to modulate pain reduction in the affected ti issues, + MRI of injured body part if symptoms continue. ASSESSMENT * This patient was noted to have a positive Deerfie! Id test, demonstrating a left short leg. After the treatment today, the Deerfield test was found to be normal. + Lack of proper joint mobility was resolved with the treatment Protocol today. + The patient appeared to tolerate the treatment well today. PLAN ‘Treatment today consisted of the following procedures and therapies: PATIENT NAME: i Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/29/2019 + Electric Stimulation (G0283). * Manual Therapy (Joint Mobilization, Manipulation, Manual Traction, Trigger Point Therapy, Myofascial Release) (97140). * Therapeutic Activities (Dynamic Activities to Restore Mobility, Strength, Balance, Coordination) (97530). * Chiropractic Manipulation 3-4 Spinal Regions (98941). Ray Schlitt, DC Page 2 of 2 Physical Medicine & Rehabilitation 25404 Highway 59 N Suite 102 Porter, Texas 77365 Phone: (281) 354-4000 Fax: (281) 354-8128 DAILY NOTE PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/30/2019 SUBJECTIVE The patient complained of the following symptoms today: * Neck pain. + Left shoulder blade pain. + Low back pain. OBJECTIVE Examination today revealed the following positive findings: + Paraspinal tenderness is found during palpation of the Cervical, Thoracic and Lumbar. + Range of Motion of Cervical Spine is restricted. * A positive Deerfield Test was noted today.. + Fixations at C4, C5, TS, T6, L5, and sacrum, + Lack of joint mobility is noted. + Myofascial dysfunction with focal muscle spasm are present in the ‘Thoracic, Lumbar and Cervical paraspinal soft tissue. DIAGN * (MS0.02) Cervical Disorder (displaced/annular tear/protrusion/de legeneration) WITH Myelopathy C4-C7. * (G54.2) Cervical Root Disorders, not elsewhere classified, * (S16.1XXA) Strain of muscle, fascia and tendon at neck level, initial encounter. + (S13.4XXA) Sprain of ligaments of cervical spine, initial encounter. + (G44.319) Acute post-traumatic headache, not intractable. + (S39.012A) Strain of muscle, fascia and tendon of lower back, initial encounter. + (S29.019) Strain of muscle Thorax. * (M99.01) Segmental and Somatic Dysfunction of Cervical Region. * (M99.03) Segmental and Somatic Dysfunction of Lumbar Region. + (M99.02) Segmental and Somatic Dysfunction of Thoracic Region. AND MMI ATION: + Treatment goals are to restore motion, improve strength and function, and reduce pain and swelling through Therapeutic Exercise and Activities. + Chiropractic manipulation to restore Proper motion segment integrity and movement with reduction of pelvic distortion eliminating Deerfield-Thomson positive findings. + Manual therapy increase active pain free ROM and increases extensibility of myofascial tissue. + Electric stimulation (interferential current) will be used to promote a fluid shift in the interstitial space of the muscle and connective tissue as well as to modulate pain reduction in the affected ti ‘issues. + MRI of injured body part if symptoms continue. ASSESSMENT + This patient was noted to have a Positive Deerfield test, demonstrating a left short leg. After the treatment today, the Deerfield test was found to be normal. « Lack of proper joint mobility was resolved with the treatment protocol today. + The patient appeared to tolerate the treatment well today. PLAN Treatment today consisted of the following procedures and therapies: PATIENT NAME: Rodri Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/30/2019 + Electric Stimulation (G0283). * Manual Therapy (Joint Mobilization, Manipulation, Manual Traction, Trigger Point Therapy, Myofascial Release) (97140). + Therapeutic Activities (Dynamic Activities to Restore Mobility, Strength, Balance, Coordination) (97530). + Chiropractic Manipulation 3-4 Spinal Regions (98941). Ray Schlitt, DC Page 2 of 2 Physical Medicine & Rehabilitation 25404 Highway 59 N Suite 102 Porter, Texas 77365 Phone: (281) 354-4000 Fax: (281) 354-8128 AILY Ni PATIENT NAME: Rodriguez, Maria DATE OF INJURY: 10/07/2019 DATE OF SERVICE: 10/31/2019 CTIVE The patient complained of the following symptoms today: « Neck pain. + Left shoulder blade pain. + Low back pain. OBJECTIVE Examination today revealed the following positive findings: + Tenderness is present in the Cervical, Thoracic and Lumbar musculature. + Restricted Cervical Range of Motion. + Asymmetrical leg lengths are noted upon completion of the Deerfield test... + Fixations at C4, C5, TS, T6, LS, and sacrum. + It was noted at the affected body part today, that there are joint mobility issues... + Myospasm of the Cervical, Thoracic and Lumbar paraspinal musculature. DIA‘ S! * (MS0.02) Cervical Disorder (displaced/annular tear/protrusion/degeneration) WITH Myelopathy C4-C7 + (G54.2) Cervical Root Disorders, not elsewhere classified. + (S16.1XXA) Strain of muscle, fascia and tendon at neck level, initial encounter. + (S13.4XXA) Sprain of ligaments of cervical spine, initial encounter. * (G44.319) Acute post-traumatic headache, not intractable. * (S39.012A) Strain of muscle, fascia and tendon of lower back, initial encounter. + (S29.019) Strain of muscle Thorax. * (M99.01) Segmental and Somatic Dysfunction of Cervical Region. * (M99.03) Segmental and Somatic Dysfunction of Lumbar Region. * (M99.02) Segmental and Somatic Dysfunction of Thoracic Region. G S AND REt TION: * Treatment goals are to restore motion, improve strength and function, and reduce pain and swelling through Therapeutic Exercise and Activities. + Chiropractic manipulation to restore Proper motion segment integrity and movement with reduction of pelvic distortion eliminating Deerfield-Thomson positive findings. + Manual therapy increase active pain free ROM and increases extensibility of myofascial