Soli Chiropractic
7240 Brooklyn Blvd, Brooklyn Park, MN 55429 路 (763) 560-0750
Initial Trauma Examination - Excerpt
- Patient:
- Doe, Jordan A. (sample)
- Date of injury:
- 03/14/20XX
- Date of exam:
- 03/17/20XX
- Mechanism:
- Rear-end MVC, restrained driver
- File / claim:
- SAMPLE-000 / NF-SAMPLE
- Referring counsel:
- Sample & Sample, LLP
Chief complaint
Objective findings
- Cervical active range of motion reduced: flexion 35掳 (norm 50掳), extension 40掳 (norm 60掳), right rotation 55掳 (norm 80掳).
- Spurling test positive on the right, reproducing radicular symptoms.
- Palpable hypertonicity and trigger points, bilateral cervical paraspinals and upper trapezius.
- Sensory hypoesthesia in the right C6 dermatome; deep tendon reflexes 2+ and symmetric.