Date: August 31, 2010

Re: Katherine Acevedo

Initial Evaluation Report

HALLANDALE MEDICAL ASSOCIATES. INC.

644 West HallandaJe Beach Blvd
Hallandale,FL33009
Tel: 954-457-8898 Fax: 954-457-8809

August 31,2010

Patient's name: Katherine Acevedo

DOA: 08/30/10

INITIAL EVALUATION REPORT

HISTORY
Ms. Acevedo, a 20 year old young woman, stated that on August 30, 2010 she was
involved in a motor vehicle accident. Ms. Acevedo reports that she was the driver of the
SUV that was traveling straight through an intersection, when it collided with a car
crossing the intersection. She did have a seat belt on. The SUV had air bags, which did
deploy, At the moment of impact, her body was straight when it was suddenly thrown
forward then backward. The patient denies trauma to head or face. She did receive
emergency care at the scene and was transported by rescue to a hospital. She was
evaluated and treated for her injuries then released later that day. Ms. Acevedo reports
feeling the following symptoms at this time: neck pain, upper and middle back pain, chest
pain, pain in the right lower leg with difficulty walking, pain of the left wrist; stiffness of
the neck and back. She presents with an. elastic bandage on the right ankle fitted at
hospital. According to the patient, she was in a good state of health until this accident
when all of her symptoms began. Because of the patient's injury her activities of daily
living have been restricted.

CURRENT SYMPTOMS

1. -Neckpain
2. Upper back pain
3. Mid back pain
4. - Chest pain
5. Right lower leg pain
6. Left wrist pain
Symptoms aggravated by: neck movement, lifting, bending, squatting, stair climbing,
walking, prolonged standing

Hallandale Medical Associates, Inc.

Date: August 31,2010
Re: Katherine Acevedo
Initial Evaluation Report

PAST MEDICAL / SURGICAL HISTORY

Noncontributory

FAMILY HISTORY
Unremarkable

REVIEW OF SYSTEMS / MEDICATIONS

Rx meds from Cleveland Medical Center p.r.n. for present symptoms from MVA
NKDA

PHYSICAL EXAMINATION
General Impression: Age: 20 Sex: P
Height: 5-4 Weight: 160 Ibs
Demeanor: coherent, tense
Posture: antalgic Ambulatory: Gait antalgic
Well developed / Well nourished
Left hand dominant

Heent; Head is normocephalic; PERLA; Extra ocular motions intact

Patient denies any visual or auditory disturbance
Oropharynx moist with no exudates; No contusions noted in
face or head areas

Thorax: No deformities noted; Respiratory excursions normal

Lung fields clear to auscultation; Tenderness noted over
chondrosternal region of chest wall bilaterally, no ecchymosis
noted; No contusions noted in abdominal areas

Cardiovascular: Pulse: 80/min., regular

Blood Pressure: 114/76 left ami, seated position

NEUROLOGICAL EXAMINATION
Patient is alert and oriented to person, place and time. Speech is normal. Memory is intact.
Cranial nerves intact bilaterally, no deficits noted. Coordination function testing
(Romberg, finger to nose to finger, heel to shin, tandem gait) normal and revealed no
dystaxia or dysmetria. Deep tendon reflexes normal, equal and symmetrical. Patient
denies any motor or sensory deficit/aberration in the upper or lower extremities nor is any
apparent at this time.

Hallandale Medical Associates, Inc.

Date: August 31,2010 ™
Re: Katherine Acevedo
Initial Evaluation Report

ORTHOPEDIC EXAMINATION
Examination of the cervical spine region: paravertebral tenderness and hypertonicity noted
bilaterally with muscle guarding noted during motioning. Compression test neg,
Distraction and Hyperflexion tests positive for localized non-radiating pain; Valsalva and
Spurling's maneuvers neg; Shoulder depression positive bilaterally for cervical pain
radiating into posterior shoulder girdles

Cervical spine ranges of motion (active) were as follows:

Flexion: restricted with pain
Extension: restricted with pain
Right Lateral Flexion: restricted with pain
Left Lateral Flexion: restricted with pain
Right Rotation: restricted with pain
Left Rotation: restricted with pain

Examination of the thoracic spine region: paravertebral and dorsoscapular tenderness and
hypertonicity noted in upper and middle ranges bilaterally with muscle guarding noted
during motioning

Examination of the lumbosacral spine region: unremarkable at this time

Dorso-lumbar spine ftrunk) ranges of motion (active) were as follows:

Flexion: full with pain in thoracic range
Extension: restricted with pain in thoracic range
Right Lateral Flexion: full
Left Lateral Flexion: full
Right Rotation: restricted with pain in thoracic range
Left Rotation: restricted with pain in thoracic range

Examination of the upper/lower extremities:

Right lower extremity: after removing elastic bandage at right ankle, pain with palpatory
point tenderness noted over outer midcalf/fibula region with mild swelling noted; limited
weightbearing; antalgic gait; inability to plantar flex foot due to pain; joint stability and
ROMs at ankle and knee WNL; no swelling or tenderness noted at ankle
Left wrist region: ecchymosis noted over palmar aspect of left wrist, active wrist ROMs
full; grip good; small skin abrasion noted

Hallandale Medical Associates, Inc.

Date: August 31, 2010
Re: Katherine Acevedo
Initial Evaluation Report

ASSESSMENT Clinical Impression:

1. Cervical Sprain/ Strain 4. Acute Fibula Fracture, right, midshaft,

2. Thoraco-dorsal Sprain/Strain transverse, nondisplaced
3. Chondrosternal Sprain/Strain 5. Contusion/Abrasion, left wrist

Based upon the history and examination, the patient's symptomatology can be directly
attributed to the aforementioned MVA.

DIAGNOSTIC PLAN
X-Rays: Cervical /Thoracic Spine, AP and Lateral views;
Right ankle/distal tibia-fibula, 2v.

TREATMENT PLAN AND GOALS

1. The patient is to be treated with a 4-5 times per week for 4 weeks coarse of physical
therapy modalities and therapeutic procedures to the cervical and thoracic spine
regions to include the following:
a. Cold and/or heat therapy, electrical stimulation, therapeutic ultrasound and
mechanical traction to facilitate reduction of muscular spasm, nerve irritation and pain
b. Massage therapy, myofascial therapy, chiropractic manipulative treatment to
promote and restore functional mobility to musculoskeletal structures and reduce
symptoms
2. Re-evaluation of patient will be made in 4 weeks; any changes to treatment and/or
adjunctive orthopaedic/therapeutic type support and recommendation for specialist/
diagnostic evaluation will be made if deemed necessary to assist patient's recovery
3. Orthopedic specialist referral for right fibula fracture

FURTHER DIAGNOSTIC/ PROGNOSTIC CONSIDERATIONS

All general measures associated with this diagnosed condition have been reviewed with
the patient. The potential risks have been described and patient has acknowledged their
understanding of them.

rank Rodriguez, DC

Hallandale Medical Associates, Inc.