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(SPECIAL NOTE: This is an unedited narrative. In other words, this is how it looked after it was generated by the Report Master Program, without any additional editing.)

Attn: Ms. Kerry McPhee

Re: Fife , Barney T., Mr.

Dear Ms. McPhee:

On January 1, 2004, Mr. Barney T. Fife presented himself for an initial examination and evaluation of his symptoms coming from a motor vehicle accident that he was involved in.

INJURY DESCRIPTION:
The time was 10:00 AM. Mr. Fife stated that he was the driver in a car which was stopped at an intersection. According to the patient, the other vehicle involved was travelling at approximately 25 m.p.h. He stated that the other vehicle struck his vehicle in the rear end.

Mr. Fife also reported that, at the time of the accident, the road conditions were clean and dry and visibility was good. In addition, he stated the damage to his car was moderate. He also stated that he did not see the accident coming, and therefore was not braced for the impact. Also, he was not wearing his seat belt, and did not have his shoulder harness on. On impact, both the driver's and front seat passenger's air bags deployed.

His car was equipped with headrests, his own headrest being even with the bottom of his head at the time of the accident. He also noted that he had his head facing straight forward at the moment of impact. The patient's body struck the inside of his vehicle on impact, "my chest hit the steering wheel." He stated that he did not lose consciousness during the accident. According to the patient, the police showed up at the scene. An accident report was filled out at that time.

INITIAL COMPLAINTS:
Immediately following the accident, the patient's main complaints included fatigue, fainting spells, anxiety, headaches, nausea and pain in the low back. Following the accident Mr. Fife was taken by ambulance to the hospital emergency room. X-rays were taken of his neck and back, which revealed nothing conclusive. Some lab work was performed which consisted of blood work. Then Mr. Fife was treated with ice and the application of a cervical collar. On release he was given instructions to go to your family doctor.

CURRENT COMPLAINTS:
An assessment was performed on Mr. Fife to determine his current signs and symptoms. His first symptom is sharp and cutting pain in the neck on the left side. He reported that the pain radiates into the head on the left side and the left shoulder. It occurs between one half and three fourths of the time when he is awake, and precludes carrying out activities of daily living. It is aggravated by coughing, sneezing and by taking a turkey out of the oven.

Mr. Fife's second stated symptom is dull and aching pain in the mid back on the left side. He stated the pain is also lancinating. He stated that this symptom radiates into the left shoulder and the left hip. It occurs between three fourths and all of the time when he is awake, and causes serious diminution in his capacity to carry out daily activities. It is aggravated by bending forward, bending backward, bending to the left and by bending to the right.

GENERAL PHYSICAL EXAMINATION:
Mr. Fife is a 44 year-old mentally alert and cooperative male.

Date of Birth: February 2, 1959

Weight: 150 pounds. Stature: Slightly underweight. Height: 5 feet 11 inches.

Deep Tendon Reflexes: Hypo-reflexia was noted in the right Biceps and right Triceps tendons. The left Biceps, left Triceps, left Brachioradialis, right Patellar and right Achilles tendons presented a normal reflex. Hyper-reflexia was noted in the right Brachioradialis, left Patellar and left Achilles tendons.

NEUROLOGICAL EVALUATION:

Lumbosacral Nerve Tests:
The Heel-Walk Test , which when positive is indicative of a lesion of the fibers of the L5 Nerve Root, was positive. The patient is told to walk on the heels several steps forward, then back the same way. If the patient has low back complaints and is unable to perform this action because of either pain or weakness, the test is considered positive.

The Toe Walk Test was positive.

ORTHOPEDIC EVALUATION:

Cervical Lesion Tests:
The Jackson Compression Test , which is usually indicative of nerve root compression, was positive on the left side. In this test, the patient, sitting upright, attempts to laterally flex the neck and head toward the affected shoulder. Then the examiner exerts downward pressure with clasped hands on top of the patient's head. The test is positive if this action exacerbates the patient's cervical and/or radicular pain indicating nerve root compression.

The Maximum Cervical Compression Test, which indicates cervical nerve root compression, was positive on the left side. In this test, the patient, sitting upright, attempts to laterally flex the neck and head toward the affected shoulder. Then the examiner directs the patient to bring the chin as close as possible to the shoulder. The test may be repeated passively if there is no response when the patient does the action actively. The test is positive when the action causes radicular pain on the side of the flexion and rotation. A positive test reveals cervical nerve root compression in that the action narrows the diameters of the intervertebral foramina as much as anatomically possible.

Sacroiliac Lesion Tests:
Erichsen's Sign , which is used to indicate sacroiliac joint disease while ruling out hip joint disease, was positive on the left side. This test is done with the patient prone. The examiner, with the hands over the dorsum of the ilia, bilaterally thrusts toward the midline. If this produces pain over the sacroiliac area, the test is positive.

Lewin-Gaenslen's Test, which usually indicates a Sacroiliac joint lesion, was positive bilaterally. In this test, the patient lies on one side and pulls the knee of that same side up to the chest, while extending the other thigh. The examiner applies additional pressure from behind, forcing extension of the other thigh. Exacerbation of pain from the pelvis is considered a positive test.

Sciatic Nerve Lesion Tests:
The Lasegue (Straight Leg Raise) Test was positive on the left side. On this patient, moderate pain at posterior thigh was elicited at 45 degrees, which may indicate low back radiculopathy or possibly a lumbar disk lesion. This test is done with the patient supine and with the knee in extension. The examiner, actively flexes each thigh slowly while holding the other hand on the knee to prevent its flexion. The leg is lifted 90 degrees or until pain prevents further motion. The final angle of flexion at which pain occurs, as well as the location and intensity of the pain are noted by the examiner. This test is considered positive when the straight leg cannot be raised to 90 degrees without pain.

Intervertebral Disc Syndromes:
Kemp's Test , which usually confirms fracture, facet syndrome, or disc involvement, was positive on the left side. This test can be done with the patient standing or sitting. While stabilizing the pelvis, the patient's shoulder is firmly forced obliquely backward, downward and medialward. The idea is to put the lower spine on the opposite side to the one being tested, into a combined position of rotation, lateral bending, and extension. The test is considered positive when low back pain radiates into the lower extremity.

X-RAY STUDIES:

Date of Study: February 2, 2003
The following films were available for review:

Cervical Spine:
Anterior-Posterior
Lateral
Oblique

Thoracic Spine:
Anterior-Posterior Upright

Radiographic Analysis:
There is no evidence of fracture present. No evidence of gross osseous pathology is apparent. There are no developmental distortions. The facet joints appear normal.

There is evidence of moderate calcinosis of the abdominal aorta. Marked osteoporosis (a decrease in the density of bones along with an increase in their brittleness) is present. Spondylosis (generalized spinal degeneration marked by stiffness of the vertebral joints) is present. Extremely advanced degenerative arthritis is present. This is also known as osteoarthritis, which results from wear and tear and trauma to the joints, usually evolving in middle age and most commonly affecting the elderly.

There appears to be marked intervertebral disc space narrowing at C3-4.

When the spinal column is viewed as an integral, contiguous structure, the vertebrae present with slight subluxation (misalignment) at C2.

Moderate osteophytosis (bony outgrowth or spurring) is noted at the anterior/inferior vertebral margin at C3.

There is moderate foraminal encroachment (narrowing of the vertebral foramen), causing bony impingement of the spinal nerves on the left side at C3-4.

There is a marked (Grade III) retrospondylolisthesis, indicating a serious sprain or disruption of the anterior longitudinal spinal ligament, involving the vertebrae at L5. There is a moderate spondylolisthesis (Grade II), indicating a sprain or disruption of the posterior longitudinal spinal ligaments, involving the vertebrae at L4.

Motion Studies:
The relative movements of the vertebrae were evaluated utilizing extension and flexion radiographs.

There was markedly deficient movement in extension at C3-4. Markedly deficient movement in flexion was noted at C3-4.

ASSESSMENT/DIAGNOSIS:

847.1 Thoracic sprain/strain

848.3 Chondrocostal Sprain/Strain

850.1 Concussion with brief loss of consciousness

723.3 Cervicobrachial syndrome (diffuse)

723.4 Brachial neuritis or radiculitis

PROGNOSIS:
Scar tissue forms not only on the skin, but on all internal lesions as well, such as muscle tears, sprains, strains or where internal surgery has been performed. As damaged tissues heal, local areas of inflammation remain chronic sources of irritation because the body repairs a wound, ulcer, or other lesion by increasing its production of the tough, fibrous protein collagen at the site of the damage. The collagen helps form new connective tissue, which covers the area of the lesion.

Adhesions are areas of scar tissue that form between internal organs and are a potential complication of not only internal surgeries, such as intestinal operations, but also of sprains, strains and other soft tissue lesions, such as those caused by Whiplash and similar trauma. This results in areas of tissue that retain fluid from the inflamed state. This further creates a weakening of the fibers, as well as creating a rigid or fibrotic state due to the "healed" but damaged tissues. (Reference: The American Medical Association Encyclopedia of Medicine, Random House, New York, 1989).

TREATMENT:
The following prescribed treatment regimen will be essential to minimize the possibility and/or degree of permanent residuals experienced by Mr. Fife:

Specific spinal adjustments
Spinal traction
Therapeutic massage
Ultrasound therapy
Whirlpool treatment

CLOSING COMMENTS:
I hope I have answered all of your questions concerning this case. If I can be of any additional assistance with regard to this matter, please do not hesitate to notify this office.

Sincerely,

John Smith, D.C.