MOTOR VEHICLE ACCIDENT, PATIENT PREGNANT WITH SPINAL STRAIN         

INITIAL DIAGNOSES:

• Chronic cervical musculoskeletal ligamentous strain.

• Chronic lumbosacral musculoskeletal ligamentous strain.

• Chronic post traumatic myofascial headaches.

• 5 1/2 month intrauterine pregnancy.

• History of gall bladder disease with recent weight loss.

PLAN:

• Medical records to be requested from Hospital.

• Cervical pillow and lumbosacral cushion to be dispensed.

• Physiotherapy prescribed 3 times weekly to include ultrasound, electrical stimulation, hot packs and therapeutic massage contingent upon authorization by treating obstetrician.

• The patient is instructed in therapeutic exercises including ball rolling.

• Tenderness patient is advised to use topical pain relief such as Aspercreme or Icy Hot and Tylenol for pain relief.
  

• The patient should avoid repetitive and/or strenuous bending or lifting greater than 10-15 pounds and any and all other activities which may aggravate her underlying condition.

• The patient is advised the effects of pregnancy may lead to progressive discomfort to her underlying condition.
  

• The patient should be reevaluated by the physician within 2 weeks.

• The patient is advised, after delivery of her child, diagnostic studies including MRI of the cervical and lumbosacral spine would be considered should her symptoms persist.

In my opinion, by medical history and physical examination, this patient’s present condition is the result of the motor vehicle accident of 11/20/98.  

The patient is presently 5 1/2 months pregnant which may contribute to a worsening of the patient’s underlying condition.  

After review of pertinent history, diagnostic studies, treatment course and upon attaining maximum medical improvement a permanent functional impairment rating based on the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, shall be established with regard to the motor vehicle accident of 11/20/98. 

THE HEALTH PLACE
A Private Medical Practice of David P. Kalin, M.D., M.P.H.
Tel  813.966.1431  Fax 813.925.1932

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