Case I
:
MOTOR VEHICLE
ACCIDENT WITH CLOSED HEAD INJURY
INITIAL
DIAGNOSES:
History of post traumatic headaches secondary to closed head injury.
Cervicothoracic sprain/strain.
Lumbosacral sprain/strain.
Post traumatic chest wall pain secondary to strain.
History of post traumatic right knee pain.
Post traumatic pain and dysesthesia left upper extremity, rule out
cervical radiculopathy, brachial plexopathy, peripheral neuropathy, effect of
thoracic outlet syndrome.
History of post traumatic pain and dysesthesia left lower extremity, rule
out lumbosacral radiculopathy, plexopathy.
Status post repair right rotator cuff,
work related injury 1995.
Status post arthroscopic surgery right knee,
slip and fall
injury 1986.
History diabetes mellitus, diagnosed 1995, on Humulin 70/30, 45 units AM,
40 units PM and Glucophage 1000 mg. BID.
History of lumbosacral strain,
motor vehicle accident 1995.
Overweight.
PLAN:
Medical records to be requested from the General Hospital and physician.
Toradol 10 mg. 1 Q6h PRN for pain #30,
Ultram 50 mg. 1 Q6h PRN for pain #30 and
Flexeril 1 Q8h PRN for muscle spasm #30, refills X2 prescribed.
Toradol injections 60 mg. intramuscularly every 5-7 days X4 as needed.
Cervical pillow and lumbosacral cushion to be dispensed.
Physical therapy prescribed 3-5 times weekly to include ultrasound, hot
packs, electrical stimulation, and neuromuscular massage.
The patient is referred for range of motion evaluation.
The patient is referred for chiropractic evaluation and treatment.
MRI of the cervical and lumbosacral spine to be ordered.
The patient should be reevaluated by
the physician within 2 weeks.
The patient is put on a no work status.
The patient should follow-up with the family physician as previously
anticipated.
Should the patient’s neurologic symptoms persist, neurodiagnostic
studies of the left upper and lower extremities including SSEP, NCV and EMG
would be considered as well as thoracic outlet study of the left upper
extremity.
In my opinion, by medical history and physical examination, this patient's present condition is the result of the motor vehicle accident of 10/23/99.
The patient has a history of work related right shoulder injury for which he had arthroscopic repair of the rotator cuff in 1995 with full recovery and a slip and fall injury for which he had arthroscopic surgery of the right knee in 1986 with full recovery.
The patient sustained a motor vehicle accident in 1995 with a lumbar strain, treated for approximately two months, with full recovery.
The patient has underlying diabetes mellitus diagnosed in 1995, for which he takes Humulin 70/30, 45 units AM and 40 units PM and Glucophage 1000 mg. BID.
The motor vehicle accident of 10/23/99 has caused the
aforementioned problems noted in the initial diagnoses, however, the patient’s
underlying diabetes mellitus may have a detrimental effect on the anticipated
treatment course.
After review of additional pertinent medical records, diagnostic studies, treatment course and upon attaining maximum medical improvement, a permanent functional impairment rating based on the The AMA Guides to the Evaluation of Permanent Impairment, 5th Edition shall be established.
THE
HEALTH PLACE
A Private Medical Practice of David P. Kalin, M.D., M.P.H.
P.O. Box 6009
Palm Harbor, Fl 34684
Tel 813.966.1431 Fax
813.925.1932 drkalin@drkalin.com
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