1. No category

Personal Injury Checklist
Page 1 of 2
Date of Injury: 9/11/11
Today’s Date: 2/3/12
2/3/12
Patient was Released to MMI Status:
Patient’s Name: Ashley W.
Doctor’s Name: Gary N. Lewkovich, DC, QME, CO
-- Based upon a review of the available records in this case, the following information has been summarized by the treating doctor. -Adverse Factors
Signs of a More Serious Injury
Pre-Existing & Complicating Diagnoses
Went to ER for this injury: Tri-City Medical Center ER
Specify:
See enclosed reports
1. Patient did not anticipate the impact.
2. Patient’s vehicle was struck from the rear.
3. Patient’s head was turned at the moment of impact.
4. Patient’s head was forward of head restraint at impact.
5. Patient was wearing a lap and shoulder restraint.
1. Prior neck sprain/whiplash:
Went to PCP for this injury:Went to MD on 9/15/11 & 9/22/11
Name:
See enclosed reports
Went to a PT for this injury: Went to a DC for 30 days of Tx
Name:
Ray S., DC/no change/see report
2. Spondylolysis:
3. Vertebral fracture C T L
4. Rheumatoid arthritis:
5. Scoliosis: Sl Mod Severe:
6. Patient experienced multiple vehicle impacts.
Had a orthopedic evaluation for this injury:
Name: Edward K, MD, for surgical consult on12/2/11
7. Patient was in the smaller of the 2 vehicles.
Had a neurological evaluation for this injury:
Name:
7. Facet arthrosis:
9. Patient has a slender neck.
Had a psych eval/Tx for this injury:
Name:
9. Anklylosing spondylitis:
10. Patient is over 65 years of age.
Had a MRI for this injury: Performed 11/15/11, see report
10. Spondylosis:
11. Patient’s vehicle sustained significant damage.
Had a CT scan for this injury: Tri-City Medical Center ER
11. Osteoporosis:
12. Loss of consciousness.
Had a fluorovideo for this injury:
12. Disc protrusion:
13. Early radicular symptoms.
Had electrodiagnostic testing for this injury:
13. Diabetes: Type 2
14. Immediate pain after impact.
Had other special diagnostic test(s):
Specify:
14. Foraminal encroachment:
See enclosed reports
8. Patient is a female.
Prius was totalled: >17 K damages
16. Patient had more than 2 weeks off work due to injuries.
17. Patient had no chiropractic care for the first 4 weeks.
18. Patient had multiple flare-ups
19. Patient had multiple periods of temporary disability.
20. Patient is a smoker.
21. Patient had below normal physical conditioning.
22. Prolonged sleep disturbances during healing process.
e
l
p
m
a
S
Medications taken during recovery for this injury:
Specify:
See above referenced reports
Current medications for this injury:
Specify:Occasional use of Ibuprofen/Vicodin for flare-ups
Fractures or surgeries due to this injury:
Specify:
Reports for above attached? Yes No
Current Symptom Levels/Rehab Progress
Current average pain levels:
(0-10 pain level)
Other (specify):
23. Prior neck or whiplash injuries.
Current maximum pain levels:
(0-10 pain level)
24. Pre-existing disc narrowing in the injured areas.
25. Pre-existing arthritic changes in the injured areas.
26. Development of trigger points/adhesions in recovery.
27. Development of a TMJ disorder during the recovery.
28. Very physically demanding work duties.
Other (specify):
30. Poor posture. Forward head tilt
Neck:
Upper Back:
Low Back:
Head
2
1
0
2
Neck:
Upper Back:
Low Back:
Head
6
4
0
8
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Abs:
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No
Disability forms enclosed? Yes
Permanent Residuals
AMA Impairment Guidelines Rating
44 % Moderate
Oswestry Disability Index for Low Back:
Raw score _2__ Percent Disability 4 % Minimal
Disabilities of the Arm, Shoulder and Hand (DASH):
Raw score __N/A_ Percent Disability _0__%
Other (specify): Headache index - Sl-Moderate Dis.
Indexes enclosed? Yes
No
19. Carpal tunnel syndrome:
20. TMJ disorder:
21. Spinal stenosis:
25. Other:
Neck:
Progress assessments enclosed? Yes
Permanent Disability Indexes
18. Spinal anomaly:
24. Degenerative disc disease:
DRE Category
Croft Whiplash Injury Grade
Grade 1
Minimal: No limitation of motion; no
ligamentous injury; no neurological findings.
Grade 2
Slight: Limitation of motion;
ligamentous injury; no neurological findings.
no
Grade 3 + Moderate: Limitation of motion;
ligamentous injury; neurological findings may be
present.
Grade 4 Moderate to Severe: Limitation of motion;
ligamentous injury; neurological findings present;
fracture or disc derangement.
patient reported 2 weeks of full disability immediately after DOI.
Neck Disability Index:
Raw score 22 Percent Disability
17. Spinal infection:
23. Extremity dislocation:
Periods of Temporary Disability
See patient’s disability log for work restrictions and date ranges.
Total Disability Period(s): The
16. Pagets disease:
22. Spondylolisthesis:
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
31. Required use of cervical collar for > 2 wks.
15. Fibromyalgia:
Rehab Progress (percent of goal obtained):
Back:
29. Incomplete exercise rehab. For neck only
Partial Disability Period(s):
8. Serious metabolic disorder:
See enclosed reports
15. Immediate or near-immediate muscle spasms.
6. Significant back sprain:
Grade 5
Severe: Requires surgical management or
stabilization.
No
Functional Loss Factors
Work Preclusions: Patient is precluded from prolonged
IV Whole Body Impairment 25%
See report for details of 25% WPI for neck
C4-C5 anterior translation instability.
forward bending of the head (8%). Occasional moderate
headaches (4%).
ROM Method ______ Whole Body Impairment ______
Based upon:
Loss of Pre-Injury Work Capacity:
Other (specify): 2% WPI for headache pains
Rating summary enclosed? Yes
Rating Estimate: 12% Disability
See enclosed report.
No
Other (specify):
Additional disability information as a result of this injury:
The patient has refused the surgical stabilization option outlined by Edward K., MD, at this time.
See his report for cost estimates.
Copyright © 2008, 2011 and 2012, by Gary N. Lewkovich, DC, All Rights Reserved
Rating summary enclosed? Yes
No
See Trauma-related diagnoses on page 2
Personal Injury Checklist
Page 2 of 2
-Trauma-Related Diagnoses and Permanent Residuals-
Diagnoses
1. Post-Concussion Syndrome
2. Mild traumatic brain injury
3. Acute, post-traumatic headache
Residuals
Y N
Sl Mod
Severe
339.21
Y N
Sl Mod
Severe
854.0
4. Chronic, post-traumatic headache
339.22
6. Cervical strain/sprain
847.0
5. Migraine:
7. Intersegmental ligament laxity
8. Late effects of sprain/strain
9. Reversal of cervical curve
346._ _
728.4
905.7
738.2
10. Cervical disc displacement
722.0
12. Brachial/cervical radiculitis
723.4
14. Carpal tunnel syndrome
354.0
16. Rotator cuff syndrome
726.1
11. Cervical nerve root lesion
13. Cervical postlaminectomy synd.
15. Thoracic outlet syndrome
353.2
722.81
353.0
17. TMJ dysfunction syndrome
524.6
19. Muscle weakness
728.87
18. Muscle spasm
20. Vertigo
21. Sleep disturbance
22. Myofascitis/Myalgia
23. Costochondritis
24. Chronic pain due to trauma
25. Facet syndrome
728.85
430.4
780.5
729.1
733.6
338.21
724.8
26. Adhesive capsulitis of shoulder
726.0
28. Thoracic strain/sprain
847.1
27. Bicipital tendinitis of shoulder
726.12
29. Lumbar strain/sprain
847.2
31. Sciatica
724.3
30. Lumbosacral strain/sprain
32. Lumbar displaced disc
33. Lumbar postlaminectomy synd.
846.0
722.10
722.83
34. Sacroiliac sprain
846.1
36. Periostitis:
730.3
38. Enthesopathy:
726.
35. Chondromalacia patella
37. Bursitis:
39. Epicondylitis:
40. Occipital subluxation:
41. Cervical subluxation:
717.7
726.
726.
739.0
739.1
42. Thoracic subluxation:
739.2
44. Sacral or coccyx subluxation
739.4
43. Lumbar subluxation:
45. Rib cage subluxation:
46. Fracture:
739.3
739.8
47. Other: C4-C5 3.5 mm translation
48.
49.
50.
Comments
310.2
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Severe
Severe
Severe
Severe
Severe
Severe
See enclosed disability forms and progress assessments
See enclosed disability forms and progress assessments
At C4-C5, anterior translation of 3 mm.
In regards to the ligamentous laxity of her cervical spine
Severe
Severe
Severe
Severe
e
l
p
Severe
Severe
Severe
Severe
Severe
m
a
S
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Sl Mod
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Less than 4 hours sleep per night first 5 weeks. Near resolved now.
See enclosed disability forms and progress assessments
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
See enclosed disability forms and progress assessments
See enclosed disability forms and progress assessments
Severe
Severe
Severe
Severe
Severe
This instability is AMA ratable at 25-28% Whole Person Impairment. With
Severe
therapy, the patient has been able to prevent this problem from requiring
Severe
major posture/ergonomic modifications, exercise rehab, and ongoing home
Severe
surgical stabilization. See Edward K., MD, report on future medical costs.
Copyright © 2012, by Gary N. Lewkovich, DC, All Rights Reserved