Monday, May 19, 2006
Mr. Robert Miller
125 Keystone Drive
Belleville, IL 62226
RE: Lincoln, Robert T.
SSN: 444-33-9999
Dear Mr. Miller:
Your client, Mr. Lincoln, consulted my office on Monday, May 19, 2004 for injuries
sustained in an automobile accident which occurred on Saturday, May 17, 2004.
History Of Complaint
Mr. Lincoln is a 35 year old gentleman who appeared to be very uncomfortable. He
stated that he exercises occasionally. He denies the use of alcohol and also denies
the use of tobacco. He is currently employed as a computer programmer. On Saturday,
May 17, 2004 Mr. Lincoln was involved in a motor vehicle accident in which his vehicle
was struck in the rear end at a relative speed of 20 miles per hour. He was in a
compact vehicle and the vehicle that struck him was a midsize. He was the driver
of the vehicle. Mr. Lincoln stated that he was wearing his seat belts when the accident
occurred and that the air bag did not deploy. He reported that at impact, the vehicle's
brakes were applied. The seat that he was sitting in did not break. Following the
accident, he stated that he went to the emergency room via an ambulance. He further
said that when the accident occurred, he did not loose consciousness. During today's
consultation, Mr. Lincoln indicated that he was experiencing constant moderate to
severe diffuse right posterior neck symptoms which were generally achy but occasionally
sharp in quality. Radiation of pain from the right posterior neck to his right elbow
was noted. The symptoms were generally worse with sitting and repetitive use of
the hands. Previous diagnostic tests which have been performed for this condition
have included plain cervical and thoracic x-rays. He has been seen by an emergency
room physician. Past treatment has included non-steroidal anti-inflammatory medications
and muscle relaxants. Today's Neck Disability Index (NDI) was graded at 45% which
is considered by the questionnaire to be a moderate disability. The review of systems
was unremarkable. Today, his zero to ten score was an 8.
Examination Findings
Cervical distraction decreased the neck pain and right arm pain. Foraminal compression
was positive on the right for the chief complaint but was negative on the left.
Shoulder depression was positive on the right. Allen's test was found to be negative
bilaterally. The costoclavicular maneuver was found to be negative bilaterally.
All of the upper extremity reflexes were graded 2/2. The right C7 dermatome was
found to be hypoesthetic via pinprick. The right biceps muscle strength was found
to be grade 1. On palpation, moderate to severe spasm and tenderness was found in
the cervico-thoracic region on the right. Active trigger points were found in the
SCM, the levator scapulae and the rhomboids on the right. On active testing in the
cervical region, flexion was measured at 5 degrees, extension was measured at 20
degrees, right rotation was measured at 20 degrees and left rotation was measured
at 20 degrees. The ranges of motion were measured using a goniometer. Audible crepitus
was present during the motion. The patient's grip strength was tested 3 times with
each hand and then the average of the 3 was recorded. The right hand measurements
were 35 lbs, 30 lbs and 35 lbs giving an average of 33 lbs. The left hand measurements
were 50 lbs, 52 lbs and 49 lbs giving an average of 50 lbs. He is right hand dominant.
His resting pulse was 76 BPM. The right brachial blood pressure was 120/80. The
cranial nerve evaluation was unremarkable. George's test was found to be negative
during the standard procedure. On spinal evaluation, a right rotation fixation was
noted at C3. Furthermore, a left lateral flexion and extension fixation was noted
at C6.
Assessment Of Condition
The primary diagnosis is still a cervical sprain strain (847.0) with associated
myospasm (728.85) which is complicated by cervical discogenic spondylosis (722.40).
I expect maximum improvement in several months. The current care is primarily corrective
in nature and the overall prognosis is fair. Mr. Lincoln may have residual mild
soreness in the neck and occasional headaches in the occipital region after treatment
is complete. The treatment may be prolonged due to underlying degenerative changes
and work activities. It is my opinion, based on Mr. Lincoln's symptoms and my physical
findings, that his condition is the result of the automobile accident which occurred
on Saturday, May 17, 2004.
Treatment Plan
The goals of care are to alleviate his symptoms, inactivate all of the trigger points
involved in his current problems and return all of his ranges of motion back to
normal levels. If significant progress is not seen in 2 weeks, I am going to refer
Mr. Lincoln to Dr. Bill Jackson for an orthopedic evaluation to rule out ligamentous
instability. I have recommended that repetitive hand movements be limited and the
use of an ergonomic chair. Chiropractic adjustment consisted of diversified maneuvers
to C3, C6 and T5. Outside the office, I have instructed Mr. Lincoln to begin to
ice the area for 30 minutes several times per day and use 5 lbs. of home traction
for 10 minutes once/day. Physical modalities used today on the neck consisted of
full range interferential EMS set to patient tolerance for 20 minutes and cold packs
for 20 minutes. We discussed alternative treatments for his condition, all of the
possible side effects of treatment performed in this office and the need for him
watch for changes in his symptoms. Mr. Lincoln indicated understanding of the items
discussed.
Thank you for referring Mr. Lincoln to my office for care. Regular progress reports
will be mailed to your office every 2 to 3 weeks. If you would like to speak with
me regarding his treatment, please call me at your convenience.
Sincerely;
Dr. Clayton T. Hoyt
CTH:dlh