For the general purpose of clarification, referrals may be made or received for purposes of consultation; concurrent care; postchiropractic care; the administration or evaluation of diagnostic procedures; or because a clear determination has been made by the practitioner that a patient's condition is outside his or her scope of professional experience.
In this case study, voice activation dictation was used for gathering data. This has become the most revolutionary means for keeping detailed and accurate charts for my practice. The chart note is dictated, then the computer processes the transcription. It becomes useful in providing an expedient method of communicating the treatment plan and relevant findings to the referring provider. As is my usual practice, I communicated by facsimile describing this initial visit of service to the case manager and medical provider on all that follows:
Chiropractic Physical Medicine Initial Report
The patient initially sought care at my facility today with complaints of neck and back pain. She rated her pain level at 7-9 on a scale of 1-10, with 10 being severe pain. The pain caused moderate interference in daily activities. The patient was provided a detailed examination with radiographic analysis of the cervical spine.
This patient is in good health overall, with the exception of six months postpartum status. The patient resides with family in "Anytown." The patient, a local resident, is left-handed. She smokes about 10 cigarettes a day. The patient reports no previous work-related injuries. There is a history of a significant and previous accidental trauma to her neck as a passenger in an automobile that incurred a frontal impact. She reports being pregnant at the time of the accident. She has had variable degrees of neck pain since this time.
The patient is allergic to sulfa; her medications include Depo-Medol. Family history reveals both parents alive; father is 60 years old, with addictive behavior reported, in accordance with the Alcohol and Alcohol Problems Science Database (ETOH); two male siblings (16 and 28) with asthma; ovarian cancer on her paternal side. She has a history of anemia, and is undergoing laboratory diagnostics, including thyroid function tests and a metabolic screening. She reported an orthopedist referral for consultation on paraesthesias of the lower limb.
On my initial examination, the patient complained of:
The patient's skin is warm, dry and pink. She ambulates without difficulty. There is no acroparesthesia, dysphagia or frank neuralgia. The thoracolumbar paraspinous region displayed some hypertonicity accompanied by limited active range of motion in scapular retraction and protraction. No crepitus or Adam's sign (scoliosis). The cervical motor or muscle testing was grade 4 throughout, with painfully slow motions augmented by flexion-extension effort, rotation movement and raising effort. The inguinal region is not tender, and the femoral nerve through it is without a purposeful withdrawal sign. There is pain and limited lumbar extension. Superficial and deep palpation of the abdomen was performed with the patient's knees bent and unremarkable. Motion palpation yielded cervical, midthoracic, lumbosacral and right sacroiliac vertebral apposition and glide restriction. A limited cervical study was obtained and reveals a reversal of cervical lordosis, creating an arc-like configuration usually associated with cervical myospasm.
Chiropractic Physical Medicine Treatment Plan
It is evident from a radiological perspective that the patient experienced a hyperflexion injury that was most likely produced by a sudden stop, as in a head-on auto collision. The two-fold trauma consists of 1) compression forces directed to the intravertebral disc, and the anterior portion of the bodies being present; 2) the traction forces affecting the posterior neural section to induce the posterior annulus fibrosus; the posterior ligament; the ligamentum flavum; the interspinous ligaments; the capsular elements; and the restraining mechanism associated with, in severe cases, dislocation. While she is able to function as a caregiver to a five-month-old infant and walk to her doctor's appointments, it may be necessary to determine the extent of injury incurred to the patient with cervical MRI, in view of her current cervical pain levels, if she fails to respond to conservative chiropractic care. Furthermore, due to injury of this type, often painful clumping of the rhomboidei and levator scapula (intrascapular) muscles with common exacerbations (the cumulative lifting of the patient's infant) may occur. It is my opinion that this condition is also secondary to her automobile accident. The alopecia and numbness may be related to postpartum thyroiditis, which I believe her primary care provider (PCP) is already investigating.
A brief discussion of postpartum thyroiditis was held with Jane Doe to explain the natural history of this suspected disorder and its relationship to the pain complaint, and that thyroid function tests find abnormalities that do not always reflect thyroid dysfunction in cases of this type. She is referred to her PCP for any endocrinology evaluations and relevant discussions.
Thank you for allowing me to participate in the active care of Jane Doe.
Nancy Molina, DC
San Juan Capistrano, California
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