Exhibit

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 1 of 16 Pg ID 144
Patient ID

Patient Name

Date of Birth

Date of injury

Date of Reevaluation

Choke House Calls

17200 10 Mile Road Suite 135

Eastpointe Ml 48021

Phone 1-586-279-3200

ITIAL_E VALUATION

1281510

03/21/2010

03/31/10

CURRENT COMPLAINTS

-Mn

HISTORY OFNESENT ILLNESS

This is female driver that was involved in an vehicle accident on 03/2112010 She was

stopped at the light and rear ended while sitting as the passenger with her boyfriend in the

same vehicle The impact was severe and both were shaken up quite bit and was

wearing seatbelt Airbags did not deploy although the car was equipped with them

EMS was not called The police showed up and said they were fine then they could go to

the hospital but EMS was not necessary The patient did not go to the ER that day but

woke the next day in severe pain Cervical pain was described as 5/10 radiating into the

right elbow and was dull in quality Thoracic spine was within normal limits Lumbar

spine was S/lO and dull bilateral radiation to the gluteal region and also left knee pain

was noted 4/10 and dull that hurts while walking down the stairs more than up the stairs

Overall she complained of headaches neck pain back pain and also left knee They

said the approximate speed of the vehicle that hit them was about 50 miles an hour from

what she could see in the rear view minor

RELEWOF SYSTEMS

As per HP

PAST MEDICAL HISTORY

Carpal tunnel on the right

FAST SURGICAL HISTORY

Only includes some teeth pulling The patient had diabetes during pregnancy She is not

pregnant at this time

FAMILY mSTORY

Positive for heart condition in her father and lung condition in her mother but she does

not know the types of the conditions She just had baby on 03/17/2009 healthy baby

OBJECTIVE FINDINGS

Vitals at the time of our examination the patient has temperature 97 degrees Fahrenheit

and pulse oximetty 97% pulse 100 blood pressure 124182 her height was 62 inches and

she weighed 185 pounds General She was well-nourished and developed in no acute

distress except for the mild discomfort secondary to the pain that she described She was

awake alert and oriented x4 HEENT Norinocephalic and atrauniatic Pupils are

equally round and reactive to light and accommodation Extraocular muscles are intact

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 2 of 16 Pg ID 145
Choice House Calls

17200 10 Mile Road Suite 135

Eastpointe MI 48021

Phone 1-586-279-3200

Page of

Patient ID

Patient Name

Date of Birth

Date of injury 03/21/2010

Date of Reevaluation 03/31/10

1281510

Cardiovascular Si and 82 No murmur rubs and gallops Pulmonary exam Clear to

auscuiatiffbulatalINiriieeiing iales or 156 WThUóthni SitiioiiteniiT

nondistended Bowel sounds x4 normoactive

Extremities Full range ofmotion No clubbing cyanosis or edema There was muscle

strength at 5/5 Neurological exam consistent with cervical spine analysis with tissue

texture abnormality assyrnetry restriction of motion and tenderness to palpation over

CS C6 and C7 Paraspinal muscle contractions were noted that are moderate in severity

Thoracic spine was analyzed and was positive only for paraspinal muscle contractions

around the VI VII and VIII These were moderate in significance Also there was

point tenderness in the spinous process at TI The range ofmotion was decreased in both

approximately 20% in all aspects worse with rotation The lumbar spine was examined

and was positive for tender point in the transverse processes as well as spinous process of

L4 andL5 this was very mild paraspinal muscle spasms that were noted The straight leg

test was performed and was negative Pinprick and sensation were intact Muscle

strength was 5/5 that was already noted

CURRNT DIAGNOSES

Cervical strain rule out radiculopathy

Thoracic strain rule out radiculopathy

Lumbar strain rule out radiculopathy

RECOMMENDATIONS

Physical therapy three sessions per week xl month

The patient instructed to take muscle relaxer Valium 10 mg one p.o b.i.d

60 dispensed and Motrin for pain 600 mg one p.o b.i.d 60 dispensed The

patient did not want narcotic The patient wanted to take care of the baby She

understood that Valium may make her feel little bit loopy but she is okay She

will only take at night to sleep while the husband takes care of the baby

Reevaluation will take in 30 days The patient understood states she will comply

our instruction and care

Martin Quiroga D.O

Transcribed by JJ Medical Systems

DO 03/31/10 DT 05/13/10 PT VIWF/

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 3 of 16 Pg ID 146
Mum/jr Pain Clink P.C

6240 Rashelle Ozive Suite 103

Flint Mi 48507

Phone 810-232-9800

Fax 810-232-7710

Patient ID

Patient Name

Date of Birth

Date of Injury 04i23t20l0

Date of Initial Evaluation 05/20/2010

INITIAL EVALUATION

3080

CHIEF COMPLAINT MVA

HISTORY OF PRESENT ILLNESS This is 49-year-old African-American female

driver that was involved in motor vehicle collision She was rear ended at an unknown

mte of speed but it was fast according to the patient while she was stopped at red light

She was wearing seatbelt The airbags vere not deployed though the vehicle was

equipped She did obtain police report EMS did not show up and nor did not go to the

hospital She states that she was shaken up by the accident quite bit however liar

emotional stute surpassed that of her physical complaint so she opted to go home instead

When she woke up the next morning she found herself to be in pain cervical pain was

7/10 in quality and sharp quality bilateral radiation with paresihesias upto the fingertips

were noted The thoracic spine was 7/10 and radiating to the right towards her chest

around the flank Her lumbar spine is worse this is Wi sharp and bilateral radiation to

the back of her knees Additionally the patient has had posttrauinatic headaches

approximately four episodes week lasting one to two hours These resolved only with

excess use of over-the-counter medication for headaches

REVIEW OF SYSTEMS As per HP1

MEDICATIONS None

ALLERGIES Penicillin which gives her hives

PRIOR INJURIES OR ACCIDENTS None

PRIOR SURGICAL PROCEDURES She had cesarean section xl

PRIOR HOSPITALIZATIONS None

FAMILY HISTORY Noncontributory

SOCIAL HISTORY She is married Denies alcohol Denies tobacco use She works

as nursing home aide

LAST DATE WORKED Presently working

EDUCATION High school completion

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 4 of 16 Pg ID 147
Mundy Pain Clinic P.C

6240 Rashelle Drive Suite 103

Fhn Ml 48507

Phone 810-232-9300

Fax 810-232-7710

Pagc2 of2

Patient JD _______________________

Patient Name

Datc of Birth _________________________

Date of Injury 04/23/2010

Date of Initial Evaluation 05120/2010

PH YSIcAL EXAMINATION Vitals She had blood pressure of 136/84 pulse 72

and respirations 1$ She is feet 10 inches and weighs 149 pounds General Well

nourished and developed in no acute distress alert and oriented x4 1-IBENT Head is

normocephalic and atraumatic Pupils are equally round and reactive to light and

acconmodation Extraocular muscles are intact Cardiovascular Si 52 No murmurs

nibs or gallops Pulmonary Clear to auscultation bilaterally No wheezing rates or

rhonchi Abdomen Soft nontender and nondistendcd Bowel sounds x4 normoaclive

Extremities Full range of motion No clubbing cyanosis or edema Neurological

Examination Cervical spine palpation on the vertebral aspects of spinous processes and

transverse processes revealed paraspinal musculature tenderness of mild-to-moderate

nature as well as spinous processes tenderness from C3 to diffusely Spurlings test

was performed and it was positive bilateral up to the fingers with parestliesias Rotation

Ilexion extension of the cervical spine was reduced to approximately 40% Sensation

slightly decreased Vibration intact Thoracic spine examination was within normal

limits Lumbar spine examination palpatory findings were that of moderate to severe

paraspinal muscle spasm with tissue texture abnormality asymmetry restriction of

motion and tenderness to palpation along the spinous processes of L3 L4 and L5

Flexion and extension of lumbar spine was reduced to approximately 25% Straight leg

test was performed and was positive bilateral 30 and 35 degrees respectively left and

right Muscle strength 5/5 Deep tendon reflexes 2/4 Gait was stable

DIAGNOSES

Cervical strain nile out radiculopathy

Thoracic strain nile out radiculopathy

Lumbar strain rule out radiculopathy

Posttrauniatic headaches

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 5 of 16 Pg ID 148
Mundy Pain Clinic P.C

6240 Rashelle Drive Suite 103

Flint Ml 48507

Phone 810-232-9800

Fax 810-232-7710

Page of

Patient ID __________________________

Patient Name

Date of Birth _______________________

Date of Injury 04/23/2010

Date of Initial Evaluation 05/20/20 10

RECOMMENDATIONS

Physical therapy and occupational therapy three sessions week x4 weeks

Pharmacotherapy with Valium 10 mg one p.o t.i.d 60 dispensed and pain

medication with Lortab .5/500 mg one p.o t.i.d 90 dispensed Additionally

the patient is to wear lumbar brace which has been prescribed to her at this time

and reevaluation to take place in 30 days Physical therapy goals to restore motor

deficits increase range of motion and reduction of pain

Martin Quiroga D.O

Transcribed by JJ Medical Systems

00 08/05/10

DT 08/06/10

PTV/WF/MW

3080

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 6 of 16 Pg ID 149
Mundy Pain Clinic P.C

6240 Rashelle Drive Suite 103

Flint1 Ml 48507

Phone 810-232-9800

Fax 810-232-7710

IMTIALVALUATION

Patient 10 2990

Patient Name

Date of Birth ____________

Date of Onset 04/27/tO

Date of Reevaluation 5/18/10

CHIEF COMPLAINT MVA

HISTORY OF PRESENT ILLNESS 54-year-old African-American female driver

who hit on the driver door side by parallel vehicle that was driving by slammed on the

break and skid into her as she was stopped at red light The patient admits to wearing

seat belt but says the airbag did not deploy although it was equipped with airbags She

obtained police report and EMS did not show up at the scene She took herself

Genesis for evaluation The patient says she had hit her head and had cervical pain that

was 7/10 sharp and dull intermittently radiating to the left shoulder Additionally the

patient had headaches that was 4/10 in pain and impact site where she hit her head was

positive for swelling The patient went to Hurley where she had negative CT for head

bleeds and thoracie spine which was within normal limits and the lumbar spine was

diagnosed with strain but complaining to be 4110 radiating to the left back of the

knee Left ankle was also strained 4/10 in pain and local

PAST MEDICAL HISTORY Seizure disorder currently negative

PAST SURGICAL HISTORY Positive only for history of migraine

MEDICATIONS Include Vicodin 5/500 and Flexeril 10 mg given to her by her

primary care physician for her MVA and previous Depakote prescription 500 rag was

given for migraine

DRUG ALLERGIES Sulfa drugs

PRIOR INJURIES None

PRIOR SURGICAL PROCEDURES She had dilatation and curettage performed as

vell as wrist surgical tendon repair in 1975

PRIOR HOSPITALIZATIONS For the dilatation and curettage as well as the surgical

tendon repair

FAMILY HISTORY Noncontributory

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 7 of 16 Pg ID 150
Mundy Pain Clinic P.C

6240 Rashelle Drive SuRe 103

Flint MI 48507

Phone 810-232-9800

Fax 810-232-1710

Page of

Patient ID

Patient Name

Date of Birth

Date of Onset

Date of Reevaluation

2990

04/27/10

5/18/10

SOCIAL HISTORY She admits to occasional alcohol and tobacco She is currently

unemployed and receiving pension

PHYSICAL EXAMINATION She is feet 10 inches tall and 165 pounds Vitals

Blood pressure 142/84 respirations 16 temperature was within normal limits and pulse

was 80 General She is well nourished and well developed in mild distress secondary

to her pain complaints Awake alert and oriented x4 and cooperative HEENT

Normocephalic and atraumatic Pupils are equal round and reactive to light and

accommodation Extraocular muscles are intact Cardiovascular exam SI and 52 No

inunnurs rubs or gallops Pulmonary exam clear to auscultation bilaterally No

wheezing rales or rhonchi The abdomen is soft nontender and distended Bowel

sounds are norinoactive Extremities Full range of motion without clubbing cyanosis

or edema Neurologic exam Cranial nerves II through XII intact No focal deficits

Pronator drift was negative The gait was stable Deep tendon reflexes were 2/4

Musculoskeletal exam she had cervical pain that was assessed and it was positive for

tissue texture abnormality asymmetry restriction in motion and tenderness to palpation

over the spinous processes of C4-C7 There were mild to moderate paraspinal muscle

spasms Sensation and vibration however were intact Spurlings test performed was

negative The patient had left ankle pain This was assessed with range of motion and

anterior drawer There was some decrease in active range of motion as well as passive

range of motion of the left ankle which produced tenderness to palpation over the medial

and lateral asp cts of the malleoli The left shoulder was assessed for pain independent

of the cervical and radicular pattern that the patient complained about It was found to be

decreased in range of motion and painful through abduction and adduction consistent

with possible shoulder strain rather than cervical radiculopathy The area was warm to

the touch and inflamed Lumbar spine was positive for paraspinal muscle spasms mild

to moderate in nature and tender points between L3 and L5 although the straight leg test

performed was negative

RECOMMENDATIONS

Physical therapy three sessions week x4 weeks

The patient has medications currently that are given by her primary care physician

so at this time pharmacotherapy will not be reemployed The patient is to take

prescription medication as indicated

Pollowup with physical therapy

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 8 of 16 Pg ID 151
Mundy Pain Clinic P.C

6240 Rashelle Drive Suite 103

Hint Ml 48507

Phone 810-232-9800

Fax 810-232-7710

Page 013

Patient ID

Patient Name

Date of Birth

Dale of Onset

Dale of Reevaluation

2990

04/27/10

5/18/10

Reevaluation will take place in 30 days

Physical therapy goals would be restoration of motor deficits reduction of pain

and increase in range of motion

Transcribed by ii Medical Systems

DD 08/25/10

DT 08/30/10

PTVTAN/MW

CMartii Dfl

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 9 of 16 Pg ID 152
Mundy Pain Clinic

6240 Rashefle Drive Suite 103

flint Ml 48507

Phone 810-232-9800 Fax 810-232-7710

INITIAL EVALUATION

Patient ID

Patient Name

Date of Birth

Date of Injury

Daie of Evaluation

August 2010

02/08/2011

The patient was not sure of date of injury some time in August 2010

HISTORY OF PRESENT ILLNESS The patient was belted driver He stated the

car he was driving was T-boned to the passenger side The patient states the driver

airbag deployed The patient states he may have been knocked out for very brief

moment He stated the airbag deployed in to his face area The patient stated when be

came to be got out of the car to make sure the other person in the other car was okay He

states the EMS arrived but he did not feel he needed medical attention at that time The

patient apparently has not had any medical attention presumably he states because he

has no insurance He stated may be three of four days after the .accident be started

noticing some headaches He stated he went to the McLaren ER where they said they

were migraines and he ws sent home The patient did not tell the ER physician that he

hadbeen in car accident few days prior The patient statS that he would get

occasional sharp pain in his neck and low back following the accident but he it was very

intermittent and was not causing him much difficulty until he stated about month or so

thereafter the accident when the neck and low back pain became more intense and more

consequent The patient states that he continues to have headache They are at the front

of his head No nausea or vomiting He states sometimes they may be throbbing in

nature There is no neurologic deficit noted He states he is experiencing some

occasional memory loss He states that sometimes he will put something down like

glass of water and then forget where he put it The headaches are not everyday They

come and go He states his neck pain is about 8/10 He states there seems to be what he

is describing some right-sided radiculopathy and he has paresthesias and both hands he

states His low back pain he states is localized there are no radiculopathy symptoms no

paresthesias and gives that about 7/10 on the pain scale The patient has not been taking

any pain medication The patient has no other complaints

PAST MEDICAL msToRy Positive for hypertension non-insulin-dependent

diabetes schizophrenic paranoia glaucoma cataracts asthma and panic attacks He

states the panic snacks started about three or four months ago and he is not sure what is

trigger those but they were not there before the accident

MEDICATIONS He is not sure of the names of He will bring the names of his

medications at next visit but ostensibly they are medications for the above-mentioned

medical conditions

ALLERGIES He has no drug allergies

SIGNIFICANT PRiOR INJURIES AND ACCIDENTS He has no prior injuries or

accidents

Page o13

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 10 of 16 Pg ID 153
.. Is

Patient ID

Patient Name

Date of Birth

Date of Injury

Date of Evaluation

August 2010

02/08/20 11

Page of

PAST SURGICALI msTORy The patient has surgical procedure nine months ago

be stated for rectal dancer There is no chemotherapy just stated it was an outpatient

surgery for rectal cancer so am not sure if this is truly what his condition was or this is

what he was led to believe it was He had no prior hospitalizations

FAMILY AND SOCIAL HISTORY He is single He has six children ages 25 to 16

The 16-year-old lives with the childs mother The patient does not drink or smoke

cigarettes The patient was laid off in July 2010 He had worked as General Motors

supplier The patients education he is high school graduate and he is presently

attending learning center four days week

PHYSICAL EXAI\IINATION Vitals Blood pressure of 140/90 Pulse 80

Respirations 14 The patient appears to be in some distress due to his injuries He is

alert He is oriented x3 HEENT Pupils are equally round and reactive to light

Extraocular muscles are intact C-spine reveals tenderness to palpation over the spinous

processes C3 through C7 with cervical paraspinal tenderness left greater than the right

Range of motion is just restricted in the horizontal plane Lungs are clear Heart Si and

52 normal without murmur Abdomen is benign Thoracic spine is nontender Lumbar

spine there is tenderness to palpation over the lumbar spinous processes L2 through L5

with bilateral lumbar paraspinal tenderness Range of motion is decreased in all planes

Negative straight leg raise bilaterally DTRs are bilaterally in upper and lower

extremities Handgrip is strong bilaterally Right shoulder reveals tenderness to

palpation over the anterosuperior aspect Range of motion is decreased in all planes and

he is unable to raise his right arm above shoulder level

IMPRESSION

Status post MVA with subsequent cervical radiculopathy

Lumbar strain

Right shoulder derangement

Postconcussive headaches with possible memory loss

Paranoid schizophrenic

Hypertension

Non-insulin-dependent diabetes

Glaucoma

Asthma

10 Cataracts

11 Panic attacks

Mundy Pain Clinic P.C

6240 Rashehe Drive Suite 103

Flint 48507

Phone 810-232-9800 Fax 810-232.7710

INITIAL EVALUATION

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 11 of 16 Pg ID 154
Patient ID

Patient Name

Date of Birth

Date of Injury

Date of Evaluation

Mundy Pain Clinic P.C

6240 Rashelle Drive Suite 103

Flint Ml 48507

Phone 810-232-9800 Fax 810-232-7710

INITIAL EVALUATION

August 2010

02/08/2011

Page of

PLAN We will get MR of his C-spine and right shoulder will geti neuropsychic

evaluation or occupational therapy to his right shoulder and head Physical therapy to his

C-spine and lumbar spine He is considered disabled Vicodin ES one b.i.d dispensed

60 Xanax mg one b.i.d dispensed 60 Recheck in 30 days

AnIrew Ruden .D

TrScthbed

by

ca1

Systems

DD 02/08/11

DT 02/09/Il

fl

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 12 of 16 Pg ID 155
Medical Evaluation

20411W l2MileRd

Southfleld Ml 48076

Phone 248-354-1111 Fax 248-354-1114

INITIAL OFFICE EVALUATION

Patient Name

Date of Birth ________________

Date of Onset 07/27/09

Date of Dictation 08/17/09

ifiSTORY OF PRESENT ILLNESS The patient was non-belted passenger in the

rear sitting behind the driver side The patient states the vehicle he was in was struck to

the front driver side The patient states that his left side of his head struck the window

He said there was no loss of consciousness but became dizzy almost immediately

few minutes later the dizziness had disappeared There were no other injuries at that

time but day or two later he says the neck became more painftil and more stiff and

noticed some tingling in both hands The patient states that since the accident he has

noticed his memory is not the same He seems to be forgetting lot but at least

forgetting things that he normally would remember and does not seem to be as sharp

mentally he says He denies any nausea vomiting or any tenderness He gets an

occasional headache The patient has not sought medical attention for any of these

injuries He has no other acute injury secondary to this motor vehicle accident other than

the neck pain with some tingling in the hands with occasional pain into his upper arms

and his memory loss with occasional headache The patient also states he sometimes has

difficulty sleeping

PAST MEDICAL HISTORY The patient is positive for depression and hypertension

FAMILY HISTORY Negative for high blood pressure diabetes or Ml

MEDICATIONS The patient takes blood pressure medicine He is not sure the name

of it and he takes antidepressant He takes Aleve over-the-counter

ALLERGIES He has no drug allergies

PRIOR INJURIES AND ACCIDENTS He has work related back injury from which

he is disabled

PAST SURGICAL HISTORY He has also had prior surgical procedures for his ankle

and knee and hand

PRIOR HOSPITALIZATION Depression and suicide attempts The patient presently

is on disability for his low back injuries as well as his ankle and leg injuries

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 13 of 16 Pg ID 156
Medical Evaluation

20411W 12 Mile Rd

Southfield Ml 48076

Phone 248-354-1111 Fax 248-354-1114

Page

Patient Name

Date of Birth _____________

Date of Onset 07/27/09

Date of Dictation 08/17/09

FAMILY AND SOCIAL HISTORY He is single He drinks occasional alcohol

Smokes an occasional cigarettes

WORK HISTORY He has not worked since 1997

EDUCATION He went through two years of college

PHYSICAL EXAMINATION He is feet and inches and 180 pounds Blood

pressure is 140/80 Pulse is 72 Respirations 14 The patient is alert and oriented

No hematoma is noted to the scalp Pupils are equal round and reactive to light Cspine there is some tenderness to the spinous processes through There is some

palpable tenderness to the paraspinals bilaterally Hand grip is strong bilaterally

Sensory exam is intact The upper extremity DTR5 are bilaterally Lungs are clear

Heart Si and S2 noted without murmur There is some lumbar tenderness to palpation

He says it is not from the injury This is from his old back injury DTRs are

bilaterally in lower extremities

IMPRESSION Status post motor vehicle accident with cervical radiculopathy

bilaterally closed head injury history of depression and hypertension

RECOMMENDATIONS N4RI of his neck and head Physical therapy to his cervical

region Prescriptions for Vicodin and Soma He is considered disabled He will be

rechecked in 30 days

.RudenM.D

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 14 of 16 Pg ID 157
Choice House Calls

17200 10 Mile Road Suite 135

Eastpointe MI 48021

Phone 1-866-688-3679

INITIAL OFFICE VISIT

Patient ID 1275660

Patient Name

Date of Birth ________________

Date of Ouset 01/06/10

Date of Evaluation 01/20/10

CHIEF COMPLAIN J$

Neck and mid back pain piln in back of both legs and headaches

InSTORY OF PRESENT ILLNESS

The patient was involved in motor velucle accident on 01106/10 He was belted

driver While stopped at red light be was rear-ended at high speed At that time he did

not feel any of the symptoms noted above and the next morning on awakening he felt all

of the above complaints along with anxiety and panic attacks He has maintained himself

on over-the-counter medications until now

MEDICATIONS

Over-the-counter pain medications

PREVIOUS JNJURIES OR ACCIDENTS

None

PREVIOUS StJRCERIES

None

PRIOR HOSPITALIZATIONS

None

SOCIAL HISTORY

He smokes approximately half pack of cigarettes day He is single

WORK HISTORI

He is unemployed He was cook until approximately two years ago and has not worked

since

PHYSICAL EXAMINATION

The patient is feet inches tall white male weighing approximately 150 pounds Blood

pressure is 112/61 Temperature is 98 Heart rate 108 beats per minute Examination of

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 15 of 16 Pg ID 158
Choice House Calls

17200 10 Mile Road Suite 135

Eastpointe MI 48021

Phone 1-866-688-3679

Page

Patient ID 1275660

Patient Name

Date of Birth _________________

Date of Onset 01/06/10

Date of Evaluation 01/20/10

the cardiovascular and respiratory systems appears normal HEENT The eyes ears2

nose and throat are normal

Examination of the spine shows tenderness along the cervical spine diffusely with

paraspinal spasms bilaterally The range of motion of the cervical spine is reduced by

50% in all planes Examination of the thoracic spine reveals moderate spasm bilaterally

Examination of the lumbar region shows tenderness along the lower lumbar spines at L4

and L5 with paraspinal spasm which are moderate-to-severe The range of motion of the

lumbar spine is reduced by 50% in all planes

He reports that the back pain appears to radiate towards the back of both upper legs He

was anxious throughout the examination and he reports occasional panic attacks

DiAGNOSES

Cervical thoracic and lumbar strain

Posttraumatic stress syndrome

RECOMMENDATIONS

Physical therapy

Pain medications such as Soma and Xanax twice day

PHYSICAL THERAPY GOALS

Short-term and long-term goals are pain management normalization of tissue tenderness

and restoration of mobility deficits to within fttnctional limits

e__j1/7t

Ram Gunabalan M.D

Transcribed by JJ Medical Systems

DD 01/24/10

DT 01/25/10

PTV/MUKJSU

2:14-cv-11700-PDB-MJH Doc # 1-10 Filed 04/29/14 Pg 16 of 16 Pg ID 159