IME Back Medical Transcription Sample Report

INDEPENDENT MEDICAL EXAMINATION (IME) SAMPLE REPORT

DATE OF INDEPENDENT MEDICAL EXAMINATION (IME):  MM/DD/YYYY

LOCATION OF INDEPENDENT MEDICAL EXAMINATION (IME):  XYZ

INTRODUCTION: The claimant was informed that this independent medical examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by the claims manager, and was not intended as a general medical examination.

The claimant was asked at the time of the examination not to engage in any physical maneuvers beyond what she was able to tolerate or which she believed were beyond her limits or which could cause harm or injury.

The examinee was instructed that the evaluation could be stopped at any time and not to allow the evaluation to continue if it caused pain.

HISTORY OF PRESENT COMPLAINT: She confirms she was involved in a motor vehicle accident on MM/DD/YYYY. She was reportedly stopped at a pedestrian crosswalk, at which point she was rear-ended by a vehicle that she quantifies as traveling about 45 miles per hour. She was seat-belted. There was no airbag deployment. She did strike the headrest upon recall but did not have any closed head injury to the frontal aspect of her head and denies any loss of consciousness.

Reportedly, it was a hit-and-run, the vehicle began to take-off, at which point she pursued the vehicle. She reports the vehicle then stopped and she had a conversation, at which point she informed the person that she would call the police if they fled; however, they did.

She, therefore, filed a police report, but she has no information as to whether the person was subsequently apprehended. The vehicle was therefore able to be driven.

Subsequent to the motor vehicle accident, the following day, she began to pursue chiropractics. She reports that she pursued this particular chiropractor based on a pamphlet that was at her insurance company that she found.

She then began treatment the following day. Initial treatment consisted of x-rays of her various areas of discomfort as well as the initiation of treatments consisting of components of therapeutic exercises, adjustments and massage.

She reports, over the course of the first week, she was seen on an everyday basis and has progressively lessened; however, she continued to be seen on a three-times-per-week basis utilizing two visits for massage therapy and one for some component of adjustments and strength work. Her last visit was yesterday.

She is also four months’ pregnant currently and therefore reports that she had less visits secondary to this pregnancy and also less participation in the treatments. She had no surgery on her low back. She had no injections or formal physical therapy or acupuncture since the accident.

CHIEF COMPLAINTS/ CURRENT CONDITION: Chief complaints currently are as following:
1. Headache.
2. Left-sided neck and upper back pain.
3. Left arm pain.
4. Left lower back pain.
5. Left thigh pain.
6. Left knee pain.

In terms of her current condition, she has pain on an everyday basis. She quantifies the pain overall at 6/10 with division of the headaches at 4/10, the low back at 6/10 and the shoulder or upper back issues at 6/10. She describes the headaches on an everyday basis typically occurring in the left occipital area with some associated nausea and photophobia.

She also describes left-sided neck and upper back issues, not really in the glenohumeral area, but more in the upper trapezial area. This overall has about 50% improvement.

She describes some radiation of symptoms down into her left upper extremity, both in the anterior and posterior aspects, which she describes as burning, paresthetic and numb.

Additionally, she has continued left-sided low back pain, which causes some radiation of pain into her anterior and posterior thigh. Overall, she reports the low back has improved by about 25%.

She has no symptoms distal to her knee but also describes pain specifically in the knee, more in the anterior and lateral aspects. This reportedly increases with ambulation.

Again, in terms of her left upper extremity, she has symptoms that extend to just distal to the elbow, but she reports that they encompass the entirety of the upper arm. She has no bowel or bladder complaints.

CURRENT WORK STATUS: In terms of current work status, she has been completely off of work since the accident.

PAST MEDICAL HISTORY:

Injuries: She reports a work-related low back injury secondary to lifting some bedspreads in (YYYY). She underwent a course of massage and physical therapy and after about two months had resolution of symptoms. She reports at the time of this accident, she was asymptomatic in terms of back, neck or extremity issues.

Prior trauma consists simply of the back injury as previously mentioned.

Time loss/work comp claims include the above mentioned back injury.

Conditions: General Medical History: None.

Operations: Ovarian cyst surgery.

Allergies: Penicillin.

Current Medications: Vitamins and fish oil.

Substance Use:

Tobacco: She does not smoke.

Alcohol: She does not drink.

SOCIOECONOMIC HISTORY:

Marital Status: She is married with two children and is currently pregnant.

Education: She has primary education.

Military Service: She has no military history.

Hobbies: Gardening and walking.

REVIEW OF SYSTEMS: Positive for the before-mentioned headaches, neck, upper back, mid back, low back and left-sided upper and lower extremity pain. She has no psychiatric history.

RECORD REVIEW: Review of medical records begins with a cover letter discussing a date of injury of MM/DD/YYYY.

Subsequent to this, there is initiation of chiropractic treatment on MM/DD/YYYY. There were x-rays performed on that day, including a cervical spine x-ray, which demonstrated no acute findings as well as a lumbar spine x-ray, which demonstrated some decreased L5-S1 height. There is also a left shoulder x-ray, which demonstrates some AC joint widening without any other obvious findings; a left knee x-ray, which is normal; and a left ankle x-ray, which is normal.

She was complaining of a combination of neck pain, mid back pain, low back pain, left-sided shoulder and hip issues as well as left knee and left ankle.

She continued treatments until MM/DD/YYYY and then on MM/DD/YYYY was seen for reevaluation noting left upper back was her worst complaint.

She continued treatments with the chiropractic center from MM/DD/YYYY to MM/DD/YYYY and on MM/DD/YYYY underwent an MRI of her cervical spine, which demonstrated some mild left-sided protrusion at T4-5.

On MM/DD/YYYY, she was seen by a provider for an evaluation. This was for a combination of neck pain, mid back pain, low back pain, left knee pain, left arm pain, and left shoulder pain. Treatment recommendations at that time were a Medrol Dosepak as well as medications for symptomatic treatment as well as continued mobilization. Recommendation was also MRI of the shoulder if she continued having problems. Again, subsequent to this, then she continued chiropractic treatment from MM/DD/YYYY to MM/DD/YYYY.

She saw the provider again on MM/DD/YYYY, noting some improvement in her pain. Recommendation was continued chiropractic therapy as well as time off work until MM/DD/YYYY. Recommended was MRI of the left shoulder.

There is then the MRI of her cervical spine on MM/DD/YYYY. Again, this demonstrated mild left paracentral disc protrusion at T4-5. There was no evidence of disc protrusion, stenosis or spinal cord impingement. There was no evidence of disc space narrowing.

Chiropractic treatments then continued between MM/DD/YYYY and MM/DD/YYYY.

There are then miscellaneous wage calculations as well as bills; estimation of damage to the vehicle, which appears to about $1400, and photos, which demonstrated some mild driver rear aspect vehicle damage. Again, these photos are somewhat suboptimal in quality.

IME PHYSICAL EXAMINATION

The claimant is right-hand dominant.

Age: (XX) years
Height: 5 feet 6 inches
Weight: 148 pounds

In terms of physical examination, she is a pleasant female who appears in no distress currently.

Evaluation of her cervical spine demonstrates essentially tenderness in the left paraspinal musculature throughout the cervical spine. There are no spasms or soft tissue swelling, and she has no midline step-off deformities.

She then has global discomfort in the left paraspinal musculature essentially from the upper thoracic spine all the way down to the S1 level. Nowhere within this span are there any spasms or soft tissue swelling. She also has discomfort in the upper trapezius and medial scapula on the left side, again without spasms or soft tissue swelling.

In terms of her lumbar spine:

Motor Exam: In upper extremities, she has symmetric 5/5 strength in her deltoid, biceps, triceps, wrist flexors, wrist extensors, FPL, EPL, and interossei; although, essentially any resistance on the left upper extremity caused her discomfort both in the combination of her neck and shoulder area.

In the lower extremities, she has 5/5 symmetric strength in her iliopsoas, quadriceps, hamstrings, gastroc-soleus, tibialis anterior and peroneals with again discomfort during any kind of resistance of her left lower extremity.

She is intact to light touch from C5 to C8 bilaterally and also from L2 to S1. She has symmetric 2+ brachioradialis, biceps, triceps, patellar and Achilles reflexes. She has a normal gait. She has some subjective decreased sensation in the left middle finger and ring finger, but again she is intact to light touch.

She has palpable tenderness along the posterior aspect of her right shoulder as well as in the anterior glenohumeral joint. She has some mild discomfort with passive manipulation of her glenohumeral joint and also with resisted supraspinatus.

Examination of her knees demonstrates:

She has anterior discomfort palpably in the left knee along the patella tendon and also along the lateral joint line. She has a negative McMurray’s test. She has a stable knee in terms of a negative Lachman’s, posterior drawer and no evidence of varus or valgus laxity.

DIAGNOSTIC STUDIES: None were submitted for review.

IME DIAGNOSES AND RELATIONSHIP:

1. Cervicothoracic strain with headaches, secondary to motor vehicle accident of MM/DD/YYYY.

2. Thoracic strain, related to motor vehicle accident of MM/DD/YYYY.

3. Lumbosacral strain, related to motor vehicle accident of MM/DD/YYYY.