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Independent Medical ExamR.P. Q.February 1, 2011ChiropractorDr. R. W. D.C.TimeObservations2:15 p.m.Client present at exam site.2:20Sign in at front desk.2:25Doctor introduces self, states he was unaware that observer would be present. 2:30Escorted back to exam room by Doctor. Client asked to sit on exam table. She is fully dressed. (Jeans, cowboy boots with 1 inch heel, fleece jacket and short sleeve tee shirt). 2:35Doctor reviews "ground rules." His speech is rapid. Client is advised to say if anything causes pain or is uncomfortable. He advises that he will be dictating at periods during the exam, and that he will be using "doc speak." 2:36Doctor; "I teach this for L&I." Begins speaking into portable tape recorder.2:37Doctor asked for completed questionnaire. When client stated she was advised not to fill it out, provider asked for name of attorney and asked to see the letter. Doctor sighed, left the room, and stated he was going to make a phone call. 2:38Doctor came back into the room with a very thick stack of papers, about 4 inches. He shuffled the papers then left the room again. 2:39Doctor returned to the room, and then left again.2:40Client states, "He doesn't look friendly now." "When a Doctor looks like that it means I'm going to get hurt." Client expresses stress at events since initial injury and ensuing pain. She states she "doesn't want a ton of money, I just want to feel better."2:42Doctor returns to the room. "It will just take me longer, and take more paperwork. The attorneys like to do this to us."2:44Doctor started questioning client, regarding current symptoms and current status. Client shows with right thumb and index finger at base of neck her current location of neck pain and headaches. Client describes current symptoms and how often, as well as exacerbating events. Client remained dressed for entire exam.2:45Client states "If I have to look up a lot, the pain gets bad." "I can only ride my quad a little right now." "I'm going to truck driving school now and by the end of the day I'm hurting." If I bend over it bothers me too, and if I'm looking down a lot.2:47Client details type of medications she is taking, but is unable to say the names. "Muscle relaxers, pain pills, anti inflammatory, all prescription."2:48Client states "If I turn too quick" in response to trigger events, and looks over her shoulder to the right. Doctor states "like checking your blind spot?"2:49Doctor asks about activities of daily living, housework, carrying groceries, etc. and pain triggers with these activities. When client answers to various questions, doctor states "If it’s about 50-60 pounds you're unhappy with that?" Client nods yes and says "yes."2:51Client states "When we did our Tillamook run, I was hurting pretty good. We left at 6:30 a.m. and came home at 5:00."2:54Doctor asks about activities that potentially cause numbness in arms and hands. Client states that hands get numb and arms become sore several times a week. "I can usually shake it off." "It’s more when I'm actually doing stuff, like when I'm on my quad.2:55Doctor "So we've got looking up, bending forward, looking down…..about 3 times a week would you say?" Client states yes.2:57Doctor "How are you sleeping?" "Is the pain waking you up, can you go back to sleep?" Client states about 2 weeks ago she had to take Advil? at night. 2:58Doctor reviews symptoms again, client considers symptoms. 2:59Doctor asks "How often are you taking over the counter medicines?" Client states about 2-3 times a week. "How often are you taking the prescriptions?" Client states she takes the muscle relaxers daily at night, the anti-inflammatory twice a day (AM and afternoon).3:00"Is this in response to pain or prophylactically?" Client states "both." 3:01Doctor "Do you use ice or heat?" Client "Ice, 3-4 times a week, usually in the evenings."3:02Doctor "What do you do to attenuate the pain?" Client states "What? What does that mean?" Doctor states "What makes it better?" Client "I go to the chiropractor." "Most of the time it goes away, when I move too quickly, but if it doesn't I take my meds or I see the chiropractor."3:02Doctor begins to dictate into tape recorder. Client sitting on edge of exam table slouched. Left leg crossed over right, swinging legs, hands clasped on knees. 3:03Doctor returns to dictating, stopping to ask more questions. 3:04Doctor resumes dictating.3:07Client is asked about pins and needles in her arms and hands while driving, and what her medication of choice is for symptom relief. Client answers "Advil?." Client is asked what else she does around the house to make it better. Client answers "The massage therapist gave me exercises, a few. They don't help."3:08Doctor asks client when she saw her primary care provider (PCP). Client answers "In January, last month." Doctor asks "About the headaches, how often are they and where are they?" Client points to base of skull with both hands. "The neck pain usually turns into a headache, and then it spreads up here" (points to hairline).3:11Doctor asks "Does the headache pain drive you to take medication?" Client answers "I wish it would just be gone." Client answers that she takes prescription medication 4-5 times a week, usually a pain pill or Advil?. She denies symptoms of sensitivity to bright light, nausea, etc. "I've had migraines for years, and it’s not a migraine." 3:15Doctor asks about the headache's pain. "Is it the intensity or location that defines the headache?" Client answers she does not understand the question. "The pain is probably about a 6 to a 7 over 10 on average. Some weeks when I'm being lazy I don't have that many."3:16Doctor and client discussed recreational activities. Client answers she enjoys her quad, and that this past weekend she went inner tubing at Snoqualmie with her husband for his birthday. "I went tubing this weekend and could only go down once. And I paid $21.00!" "I took an anti inflammatory before I went, and a muscle relaxer when I got back to the room, then 3 Advil? two hours later."3:18Client states "Riding my quad three times a week, that’s my stress reliever. I get rid of all my crap and release all the stress. Some people have horses I have a quad." "Now, maybe once a week if I'm lucky since it starts to hurt after I'm on it for a little bit." 3:19Doctor asks about low back symptoms. Client points to low back, to the left sacral area. Client begins to show irritation with questioning. She becomes more restless and jaw is clenched. Doctor again asks questions related to pain exacerbation in relation to house work, activities of daily living, and recreational activities. Client answers "Only when riding my quad, then the back pain is about a 2 to a 3 over 10."3:22Client states that low back pain does not initiate with sitting or driving, and only begins after she has ridden her quad for a bit. She states she does not take medication to alleviate the low back pain, she denies pain radiating down her legs, she denies paresthesias. Client states she uses "ice and heat" if the back becomes sore. 3:25Doctor dictating into tape recorder.3:26Doctor asks "Do you do any stretching or anything? And how did this start by the way? Tell me what happened." Client states she was stopped on the onramp, on the Chehalis bridge, waiting to merge on 4th of July weekend. "The next thing I knew, I was hit from the rear by this Daewoo. The truck moved forward a bit. I got out, checked to make sure they were ok, and then I called 911 to report it. The girlfriend of the guy said she saw it coming but couldn't do anything to stop it." "I was sitting slightly turned, looking over my left shoulder at traffic coming up the bridge. My right hand was on top of the steering wheel." Client states she did not see the car coming in the mirror. She denied loss of consciousness. Client states she was in her pickup truck-Dodge 4x4, 1500. Driver, wearing both lap and shoulder belts. Client states that the vehicle damage to the car that hit her included the entire hood crumpled to the windshield. 3:30Client states "I didn't feel it until a few hours later, and more the next day. I used some ice, my husband made me. I saw the chiropractor on Monday."3:35Client states chiropractor took X-rays and she initially saw him for treatment 3 days a week. Then she went down to one day a week, and now is back to twice a week. "I get massage every time I see him too."3:36Client states that her family MD prescribed medications as "I was eating too much Advil? when I was seeing the chiropractor." Doctor asks questions related to medical history: birthday, how many pregnancies, smoker, alcohol use, hobbies, etc. Doctor also asks client if she takes any other medications. Client "Is that really important? I take an inhaler, for emphysema. No one else knows that, I usually tell them to go to hell."3:37Doctor asks client if there have been any lifestyle changes. Client states "I can't do much of anything anymore. I used to have the best looking front yard in the area, now it looks like crap!"3:38Doctor asks about any past surgeries. Client states "Why do you need to know about my surgeries?" Client asks "Why do you have to keep asking me about my medical history, what does this have to do with this?!" (This nurse explains importance of gathering complete medical data in order to provide the best care and outcome for client). Client becomes calmer and agrees to answer the questions. Doctor asks medical history related to client's family.3:40Doctor asks "Have you ever wrecked your quad?" Client answers "no."3:42Doctor asks percentage of improvement with chiropractic, medication, massage and ice/heat. Client answers 50% improvement in the neck area, 90% improvement in the low back. 3:44With more questioning regarding improvement of symptoms client states that 20% of the 50% neck improvement has been since November 2010. Client states she has not received any physical therapy or been referred for this modality. Client states she has received the most improvement in her low back symptoms. 3:46Doctor resumes dictation again. Doctor states "This is where when you have the forms done it makes my job easier."3:52Doctor asks about surgical history again. Client states "Do I have to tell you all my surgeries?" Client then agrees to detail surgeries. Approximately 5 years ago she had a "sweat gland tumor" removed from behind her left ear, which also involved some nerve impingement of her left eye. This then involved a "gold weight" applied to the left eyelid for it to close properly. Two ganglion cysts removed from the left wrist, left thumb tendon surgery related to tendon rupture, and a 19 day hospital stay (1988?) related to a nonspecified infection. Client states 2 lymph nodes were biopsied but were inconclusive. Client states that during these 19 days she had a chest tube, and was fed intravenously through a line in her neck. 3:58Client is asked her age and weight. Client answers "44, 135 pounds. That’s what’s on my driver’s license and I'm sticking to it."3:59Physical exam started. Client removed her jacket, moves easily, no grimace noted. Doctor manipulates the BP cuff, stating it is not like his in Olympia. After several attempts, client's blood pressure is taken. Blood pressure left arm, client seated is 116/80. Client rocking side to side a bit on the exam table swings her legs forward and back a few times. 4:00Client stands for exam. She bends forward-no grimace. Client bends side to side-no grimace. Chin to chest, no grimace, although she states there is some pain. Client twists side to side-no grimace. Client gets up on her toes, and then rocks back on her heels, no grimace or complaint. Ears to shoulder left then right-no complaint or grimace. Client squats down, no grimace. Client turns her head to the left-no grimace. Turns head to the right-some grimace with complaint of discomfort. 4:02Client stands straight with her hands in her jeans pockets. She moves her head to the left and right again, slowly, with grimace.4:03Client places her arms to her sides, and then resists them to Doctor's pressure-no grimace. Client lays down supine on exam table. Head on pillow. Doctor palpates client's head and neck and manipulates spine. Client complains of some pain when Doctor pushes down on her head and the top of the neck.4:04Client's legs are lifted and placed in a series of positions: lifted up straight, then with knee bent towards chest, and hip/knee rotated and crossed over opposite leg. No grimace with maneuvers done to both legs or complaint of back pain. 4:04Client sits at side of exam table. Percussion hammer used on both left and right elbow, left heel and right heel without grimace. 4:05Client tense, and states she anticipates pain with further exam.4:05Client shrugs, pulls up arms and then fingers to resistance from Doctor. Client pushes elbows against resistance, as well as legs. Complete neuro and strength exam done, client moves all extremities well without grimace. 4:06Client lays prone on exam table, pillow under face/chin. Doctor palpates spine from neck to low back. Client moans when low back palpated and mid back at the bra line. Client places arms at her side as Doctor brings her legs up one at a time and places them in a series of maneuvers. Legs are brought up straight, then with knee bent, heel to buttocks. Legs are crossed over the opposite leg, all while Doctor is pushing gently on low back. 4:08Client complains of pain at right sacroiliac joint. This area palpated with closed fist by Doctor, then left buttock. Client complains of some tenderness to both areas.4:10Doctor palpated occipital area again while patient supine. Client looks at this nurse with questioning look and rolls her eyes. 4:12Doctor asks client what her "dream treatment" would be. Client states "No headaches and back pain again, and I can jump on my quad and enjoy."4:13Exam ended, client states she has no questions for Doctor. 4:18Client and this nurse left the exam room and walked through office and out to parking lot. 4:20This nurse answered some questions for client regarding the next steps. Both client and nurse left exam site. ................
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