Dozier v. Commissioner of Social Security

Filing 20

REPORT AND RECOMMENDATION SOCIAL SECURITY re 17 MOTION for Summary Judgment filed by Commissioner of Social Security be DENIED, 13 MOTION for Summary Judgment filed by Karla K. Dozier be DENIED and civil action be REMANDED. Objections to R&R due 10 days after receiving this R&R. Signed by Magistrate Judge James E Seibert on 8/25/09. (mji)

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA KARLA K. DOZIER, Plaintiff, v. MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant. REPORT AND RECOMMENDATION SOCIAL SECURITY I. Introduction A. Background Plaintiff, Karla K. Dozier, (Claimant), filed a Complaint on November 26, 2008 seeking Judicial review pursuant to 42 U.S.C. § 405(g) of an adverse decision by Defendant, Commissioner of Social Security, (Commissioner).1 Commissioner filed his Answer on February 3, 2009.2 Claimant filed her Motion for Summary Judgment on March 3, 2009.3 Commissioner filed his Motion for Summary Judgment on May 4, 2009.4 B. The Pleadings 1. 2. Plaintiff's Brief in Support of Motion for Summary Judgment. Defendant's Brief in Support of Motion for Summary Judgment. Civil Action No. 5:08-CV-174

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Docket No. 1. Docket No. 10. Docket No. 13. Docket No. 17.

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C.

Recommendation I recommend that: 1. Claimant's Motion for Summary Judgment be DENIED AND this action be

REMANDED because the ALJ failed to consider and give appropriate weight to the 2002 determination of ALJ Stark finding Claimant to be disabled. On remand, the ALJ must consider the prior finding and give it appropriate weight in light of all relevant evidence. Additionally, the ALJ must explicitly indicate the weight given to all relevant evidence in reaching his determination. 2. Commissioner's Motion for Summary Judgment be DENIED for the same

reasons set forth above. II. Facts A. Procedural History On January 3, 2006, Claimant filed an application for Supplemental Security Income ("SSI") alleging the onset date of disability to be January 17, 2008 due to back pain and depression. (Tr. 126). This application was denied initially (Tr. 97), and upon reconsideration on October 11, 2006. (Tr. 103). On December 12, 2006, Claimant submitted a request for a hearing before an ALJ. (Tr. 107). A hearing was held on July 15, 2008 at which Claimant and a vocational expert testified. (Tr. 42-76). The ALJ denied the claim by written decision on September 12, 2008 finding that Claimant was not disabled because, although she could no longer perform her past relevant work, she could perform other specific unskilled sedentary work that existed in significant numbers in the national economy. (Tr. 32-41). Claimant's Request for Review was timely filed on October 16, 2008. (Tr. 8). On October 23, 2008, the Appeals

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Council denied the request. (Tr. 1-3). Therefore, on October 23, 2008, the ALJ's decision became the final decision of the Commissioner. Having exhausted her administrative remedies, Claimant filed this action, which proceeded as set forth above. B. Personal History Claimant was forty-six years old on the alleged onset date of January 17, 2006. Claimant's date of birth is April 26, 1959 (Tr. 138). Claimant was therefore considered a "younger person," under age 50, under the Commissioner's regulations on both the onset date and date of the ALJ's decision. 20 C.F.R. §§ 404.156(c), 416.963(c) (2008). From the date of the ALJ's decision, Claimant has been a "person closely approaching advanced age" within the meaning of the regulations. 20 C.F.R. § 404.1563(d), 416.963(d) (2009). Claimant graduated from high school. (Tr. 148). Claimant has prior work experience as a data entry clerk in the mortgage industry. (Tr. 144). C. Medical History The following medical history is relevant to the issues of whether the ALJ erred in failing to give appropriate weight to the treating physicians' opinions which led to an initial disability finding and whether he erred in determining Claimant's RFC: Psychosocial Assessment, Jessie L. Rayl, M.A., LPC, Eastridge Health Systems, Berkeley County Office, 4/14/99 (Tr. 198-200) Psychiatric History: In and out of various drug and alcohol treatment centers; never stayed with any program. No previous history of mental illness. No family history of mental illness or substance abuse. Substance Abuse History: History of crack cocaine addiction. Began smoking "reefer" as a teenager; began smoking crack when she was 27. Stopped using all drugs in 1996. Drinks alcohol occasionally. Family and Childhood History: Was raised by her grandparents; saw her mother on the weekends. Did not have a good relationship with her father as a child but is on a friendly basis 3

now. Denied ever being sexually or physically abused. Had friends in school; did well academically. Graduated from high school. Adult History: Worked in fashion stores and accounting. Never been able to keep jobs long because of her drug use or because of personality conflicts with coworkers. Never married. Had an abortion and had PTSD symptoms for years. Social Assessment: Very little socialization since giving up drugs. Mental Status Evaluation: Reportedly feels hyperactive, worked up, tense, and anxious most of the time. Has days where depressed, despondent, and isolative. Decreased appetite recently. Sleeps four to five hours each night. Denied any suicidal ideation, previous attempts, homicidal ideation or attempts, violence to self or others, hallucinations or delusions. Obsessed with legal issues and treatment of her mother. No hygiene difficulties. Abrupt but friendly manner; affect mixed with depression and euphoria. Some flight of ideas; able to be redirected but with difficulty. No psychosis present. Average to above-average intellect. Fair insight. Recommendations: individual psychotherapy; psychiatric evaluation. S.O.A.P. Notes, Kerry V. Bertschinger, D.C., 1/3/01 - 6/21/02 (Tr. 201-230) 1/3/01 Subjective: pain in lower back and hip is worse; popping/cracking sensation in left and right groin area, pain across tops of left and right shoulders, left and right shoulder pain, pain and numbness in left and right arm, popping and cracking in joints, and pain in middle back is improved. Objective: muscle tightness in cervical spine, decreased range of motion in cervical spine, muscle tightness in upper thoracic spine, decreased range of motion in upper thoracic spine, muscle tightness in thoraco-lumbar spine, and decreased range of motion in thoraco-lumbar spine have improved; muscle tightness in lumbo-sacral spine, decreased range of motion in lumbo-sacral spine is worse. Assessment: patient continues to slowly improve. Plan: return in two weeks Treatment: specific posterior adjustive procedures administered. Specific side posture adjustive procedures were administered to the sacram. Affected extremities were adjusted. 1/18/01 Subjective: pain in lower back bilaterally, pain in hip bilaterally, popping and cracking in left and right groin area, popping and cracking in joints, pain in middle back, and pain and numbness in left and right arm have slightly improved; pain across tops of left and right shoulders, left and right shoulder pain is slightly worse. Objective: muscle tightness in cervical spin, muscle tightness in lumbo-sacral spine, decreased range of motion in thoraco-lumbar spine, muscle tightness in thoraco-lumbar spine, and decreased range of motion in thoraco-lumbar spine have improved; decreased range of motion in cervical spine, muscle tightness in upper thoracic spine, and decreased range of motion in upper 4

thoracic spine have slightly improved. Assessment: overall condition is worse Plan: return in two weeks Treatment: Specific posterior adjustive procedures were administered. Affected extremities were adjusted. 2/1/01 Subjective: pain in lower back bilaterally; pin in hip bilaterally; popping/cracking in left and right groin area; pain across tops of left and right shoulders; left and right shoulder pain; pain and numbness in left and right arm; popping and cracking in joints; middle back pain; pain in back of upper arm and arm pit bilaterally; pain in lower and middle back. Stated fell on ice and aggravated back. Objective: muscle tightness in cervical spine; decreased range of motion in cervical spine; muscle tightness in upper thoracic spine; decreased range of motion in upper thoracic spine; muscle tightness in lumbo-sacral spine; decreased range of motion in lumbo-sacral spine; muscle tightness in thoraco-lumbar spine; decreased range of motion in thoraco-lumbar spine; muscle spasms in thoraco-lumbar spine and lumbo-sacral spine; decreased range of motion in thoracolumbar spine and lumbo-sacral spine. Assessments: Flare-ups in patient's condition Plan: return in one day Treatment: Specific posterior adjustive procedures were administered. Affected extremities were adjusted. Cranial manipulation performed. Lumbar stretch. Diagnosis: lumbar sprain; lumbago 2/2/01 Subjective: pain in back of upper arm and arm pit bilaterally is slightly improved; pain in lower and middle back is slightly improved. Stated fell on ice and aggravated back. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are improved; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is improved. Assessment: patient continues to slowly improve. Plan: return next week Treatment: Specific posterior adjustive procedures were administered. Affected extremities were adjusted. Cranial manipulation performed. Neck stretch; lumbar stretch. 2/7/01 Subjective: pain in back of upper arm and arm pit bilaterally is slightly worse; pain in lower and middle back is slightly worse; tightness in neck. Stated lifting mother aggravates neck and shoulders. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are improved; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is improved; muscle tightness in cervical spine. Plan: return next week Treatment: Specific posterior adjustive procedures were administered. Affected extremities were adjusted. Cranial manipulation. Neck stretch; lumbar stretch. 5

2/15/01 Subjective: pain in back of upper arm and arm pit bilaterally is slightly worse; pain in lower and middle back is slightly worse; tightness in neck is slightly worse. Stated lifting mother aggravates neck and shoulders. Objective: Muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly worse; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly worse; muscle tightness in cervical spine is slightly improved. Plan: return next week Treatment: Specific posterior adjustive procedures were administered. Affected extremities were adjusted; cranial manipulation. 3/12/01 Subjective: no change in pain in back of upper arm and arm pit bilaterally; no change in pain in lower and middle back; no change in tightness of neck. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly improved; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly improved; muscle tightness in cervical spine is slightly improved. Plan: return next week Treatment: Specific posterior adjustive procedures were administered. Affected extremities were adjusted; cranial manipulations performed. 5/23/01 Subjective: pain in back of upper arm and arm pit bilaterally is worse; pain in lower and middle back is worse; tightness in neck is worse; cracking of joints. Stated neglected own health while caring for mother. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are worse; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is worse; muscle tightness in cervical spine is worse. Assessment: Flare-ups in condition. Plan: return next week Treatment: Specific anterior and posterior adjustive procedures were administered. Affected extremities were adjusted; neck stretch; lumbar stretch. Infrared treatment; therapy performed. 5/30/01 Subjective: no change in pain in back of upper arm and arm pit bilaterally; pain in lower and middle back is slightly improved; no change in tightness in neck; cracking in joints. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly improved; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly improved; muscle tightness in cervical spine is slightly improved. Assessment: overall assessment is slightly improved Treatment: Anterior adjustive procedures administered; specific posterior adjustive procedures administered. Cranial manipulation. Neck stretch. Infrared treatment; therapy performed. 8/8/01 6

Subjective: pain in back of upper arm and arm pit bilaterally is slightly worse; pain in lower and middle back is slightly worse; tightness in neck is slightly worse; cracking in joints is slightly worse. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly worse; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly worse; muscle tightness in cervical spine is very slightly worse. Treatment: anterior adjustive procedures administered; specific posterior adjustive procedures administered. Cranial manipulation performed. 8/15/01 Subjective: pain in back of upper arm and arm pit bilaterally is worse; pain in lower and middle back is worse; no change in tightness in neck; no change in cracking in joints. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly improved; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly improved; no change in muscle tightness in cervical spine. Assessment: overall condition is slightly worse Plan: return in two weeks Treatment: anterior adjustive procedures; specific posterior adjustive procedures. Cranial manipulation performed. 9/5/01 Subjective: pain in back of upper arm and arm pit bilaterally is very slightly improved; pain in lower and middle back is very slightly improved; tightness in neck is slightly improved; cracking in joints is slightly improved. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly improved; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly improved; muscle tightness in cervical spine is slightly improved. Assessment: overall assessment is slightly improved Treatment: Anterior adjustive procedures administered; specific posterior adjustive procedures administered. Lumbar stretch. Cranial manipulation performed. 9/19/01 Subjective: no change in pain in back of upper arm and arm pit bilaterally; no change in pain in lower and middle back; no change in tightness in neck; no change in cracking of joints. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly improved; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly improved; muscle tightness in cervical spine is slightly improved. Assessment: overall assessment is slightly improved Plan: return in three weeks Treatment: anterior adjustive procedures administered; specific posterior adjustive procedures administered. Cranial manipulation performed. 10/10/01 Subjective: no change in pain in back of upper arm and arm pit bilaterally; no change in pain in 7

lower and middle back; no change in tightness in neck; no change in cracking of joints. Objective: no change in muscle spasms in thoraco-lumbar spine and lumbo-sacral spine; no change in decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine; muscle tightness in cervical spine is very slightly improved. Assessment: overall assessment is slightly improved Plan: return in four weeks Treatment: anterior adjustive procedures administered; specific posterior adjustive procedures administered. Cranial manipulation performed. 11/7/01 Subjective: pain in back of upper arm and arm pit bilaterally is worse; pain in lower and middle back is worse; tightness in neck is worse; cracking of joints is worse. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly worse; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly worse; muscle tightness in cervical spine is slightly worse. Assessment: overall condition is slightly worse Plan: return in four weeks Treatment: specific posterior adjustive procedures administered; specific side posture and adjustive procedures administered. Cranial manipulation performed. Neck distraction. 12/5/01 Subjective: pain in back of upper arm and arm pit bilaterally is very slightly improved; pain in lower and middle back is very slightly improved; tightness in neck is very slightly improved; no change in cracking of joints. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly improved; decreased range of motion in thoraco-lumbar spine and lumbo-sacral spine is slightly improved; muscle tightness in cervical spine is slightly improved. Assessment: patient continues to slowly improve. Plan: return on as needed basis Treatment: specific posterior adjustive procedures administered. 12/17/01 Subjective: no change in pain in back of upper arm and arm pit bilaterally; pain in lower and middle back is slightly worse; tightness in neck is slightly improved; no change in cracking of joints. Objective: muscle spasms in thoraco-lumbar spine and lumbo-sacral spine are slightly worse; decreased range of motion in the thoraco-lumbar spine and lumbo-sacral spine is slightly worse; no change in muscle tightness in cervical spine. Assessment: overall condition is slightly worse Plan: return in one day Treatment: specific posterior adjustive procedures were administered. Cranial manipulation. 4/11/02 Subjective: Stated condition is chronic and continually worsening. Pain in arms bilaterally; 8

joints crack; pain and stiffness in neck bilaterally; light-headed; pain and stiffness in upper back bilaterally, ribcage pain/pulling sensation; pain in lower back bilaterally. Objective: Shoulder Depressor test of the cervical spine was positive on the left; Foramina Compression test of the cervical spine was negative; Lasegue's test of the hip was negative bilaterally; Patrick Fabere's test of the hip was negative bilaterally. Muscle tightness in cervical spine on right; decreased range of motion in cervical spine on right; muscle tightness in upper thoracic spine bilaterally; decreased range of motion in the upper thoracic spine bilaterally; muscle tightness in the mid-thoracic spine bilaterally; decreased range of motion in the midthoracic spine; muscle tightness in the lumbo-sacral spine bilaterally; decreased range of motion in the lumbo-sacral spine bilaterally. Assessment: flare-ups in condition Plan: return next week Treatment: specific posterior adjustive procedures administered. Cranial manipulation; neck distraction. Diagnosis: degeneration of cervical intervertebral disc; myalgia and myositis, unspecified. 4/29/02 Subjective: Stated condition is chronic and continually worsening. Pain in arms bilaterally is very slightly improved; no change in cracking of joints; pain in neck bilaterally is very slightly improved; stiffness in neck bilaterally is very slightly improved; light-headed; no change in pain in upper-back bilaterally; no change in stiffness in upper back bilaterally; ribcage pain/pulling sensation is slightly improved; no change in pain in lower back bilaterally. Objective: muscle tightness in cervical spine on right is slightly improved; decreased range of motion in cervical spine on right is slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in mid-thoracic spine bilaterally is very slightly improved; decreased range of motion in mid-thoracic spine is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is slightly improved. Assessment: continues to slowly improve Plan: return in two weeks Treatment: specific posterior adjustive procedures administered. Cranial manipulation; neck distraction. 5/31/02 Subjective: Stated condition is chronic and continually worsening. No change in pain in arms bilaterally; no change in cracking of joints; no change in pain in neck bilaterally; no change in stiffness in neck bilaterally; light-headed; pain in upper back bilaterally is very slightly worse; stiffness in upper back bilaterally is very slightly worse; ribcage pain/pulling sensation is slightly worse; pain in lower back bilaterally is very slightly worse. Objective: muscle tightness in cervical spine on right is slightly worse; decreased range of motion in cervical spine on right is slightly worse; muscle tightness in upper thoracic spine bilaterally is worse; decreased range of motion in upper thoracic spine bilaterally is worse; muscle tightness in mid-thoracic spine bilaterally is worse; decreased range of motion in mid9

thoracic spine is worse; muscle tightness in lumbo-sacral spine bilaterally is very slightly worse; decreased range of motion in lumbo-sacral spine bilaterally is very slightly worse. Assessment: overall condition is slightly worse Treatment: specific posterior adjustive procedures were administered. Cranial manipulation. 6/7/02 Subjective: Stated condition is chronic and continually worsening. Pain in arms bilaterally is very slightly worse; cracking of joints is very slightly worse; pain in neck bilaterally is slightly worse; stiffness in neck bilaterally is slightly worse; light-headed; pain in upper back bilaterally is slightly worse; stiffness in upper back bilaterally is slightly worse; ribcage pain/pulling sensation is slightly worse; pain in lower back bilaterally is very slightly worse. Objective: muscle tightness in cervical spine on right is very slightly worse; decreased range of motion in cervical spine on right is very slightly worse; muscle tightness in upper thoracic spine bilaterally is slightly worse; decreased range of motion in upper thoracic spine bilaterally is slightly worse; muscle tightness in mid-thoracic spine bilaterally is very slightly worse; decreased range of motion in mid-thoracic spine is very slightly worse; muscle tightness in lumbo-sacral spine bilaterally is very slightly worse; decreased range of motion in lumbo-sacral spine bilaterally is very slightly worse. Plan: return in two weeks Treatment: Specific posterior adjustive procedures were administered. Cranial manipulation. 6/21/02 Subjective: no change in pain in arms bilaterally; no change in cracking of joints; no change in pain in neck bilaterally; no change in stiffness in neck bilaterally; light-headed condition is slightly improved; no change in pain in upper back bilaterally; no change in stiffness in upper back bilaterally; ribcage pain/pulling sensation is improved; no change in pain in lower back bilaterally. Objective: muscle tightness in cervical spine on the right is improved; decreased range of motion in cervical spine on right is improved; muscle tightness in upper thoracic spine bilaterally is improved; decreased range of motion in upper thoracic spine bilaterally is improved; muscle tightness in mid-thoracic spine bilaterally is improved; decreased range of motion in midthoracic spine is improved; muscle tightness in lumbo-sacral spine bilaterally is improved; decreased range of motion in lumbo-sacral spine bilaterally is improved. Assessment: continues to slowly improve Plan: return in two weeks Treatment: Specific posterior adjustive procedures were administered. Cranial manipulation. 4/22/02 Complaints: chronic pain in and under arms; joints cracking; shoulder stiffness; back pain Objective: left and right arm pain; joints cracking; neck pain and stiffness; light-headed; upper back pain and stiffness; pain/pulling sensation in ribcage; low back pain Treatment: spinal adjustments 2/1/01 10

Treatment: spinal adjustments Radiology Report, John Blanco, MD, City Hospital, Inc., 6/14/2001 (Tr. 231) Clinical Indication: disability determination PA and Lateral Chest: Cardiovascular silhouette is normal in size and configuration; lungs appear clear. No pleural fluid noted. No bony abnormality seen. Impression: normal chest Magnetic Resonance Imaging Report, Hojoon Jung, MD, City Hospital, 10/5/04 (Tr. 232) MRI of Left Knee Without Contrast Findings: anterior and posterior ligaments are intact. Collateral ligaments are intact. No evidence of meniscal tear in medial meniscus. Evaluation of lateral meniscus demonstrates discoid configuration of the lateral meniscus without a definite tear. Seven mm osteochondral lesion involving the medial femoral condyle trochlear groove with mild subchondral edema. Moderate joint effusion. Impression: Seven mm osteochondral lesion in medial femoral condyle trochlear groove; moderate joint effusion; discoid lateral meniscus. Medical Records, John A. Draper, MD, FACS, 2/28/01 - 12/21/04 (Tr. 233-246) 12/21/04 Complaints: seeing a massage therapist; left knee feels better but still cracks; cracking in right leg but does not hurt. Physical Exam: walking better; no effusion in either knee. Full extension of both knees and able to flex both to 130 degrees. Medical Decision: contusion on left shoulder and left knee Plan: treated with Bextra and encouraged to stay active. Arthroscopy not necessary 11/17/04 Complaints: left shoulder, injected during last visit, is better. Chronically tired; left knee feels better when walking. Still taking Bextra, Flexeril, and Darvocet. Overall, feeling better. Physical Exam: able to abduct and forward flex to 120 degrees; internal and external rotation is better. Still has some crepitus in left knee; no instability. No effusion. Medical Decision: contusion left shoulder and left knee Plan: sounds like same body parts were injured in both accidents. Return in one month. May need arthroscopy of left knee. 11/2/04 Complaints: second automobile accident on October 28. Increased stiffness in neck and increased pain in left shoulder and left knee. Physical Exam: Tender to palpation over the anterior aspect of the left shoulder. Can abduct and forward flex to 90 degrees. Diffusely tender over neck and lumbosacral spine. No effusion in right knee; 1-2+ effusion in left knee. Able to fully extend left knee but only flex it to 90 degrees. No instability to anterior, posterior, or varus/valgus stress. Medical Decision: aggravation of pre-existing problems with left shoulder and left knee. 11

Plan: Accident should be only a temporary setback. Continue taking Darvocet and Bextra. Left shoulder injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Encouraged to stay as active as possible and return in two weeks. 10/14/04 Complaints: MRI of knee showed a discoid meniscus and an osteochondral lesion in trochlear groove portion of the medial femoral condyle. Physical Exam: left knee is puffy; lateral joint line and medial joint line tenderness. No instability to anterior, posterior, or varus/valgus stress. Radiographs: no defects shown in single tunnel view of knee Medical Decision: contusion left knee, which may have aggravated pre-existing discoid meniscus or caused an osteochondral fracture. Plan: Patient refused arthroscopy. Return in two months. 9/29/04 Complaints: left knee still hurting; infrequent twinges of pain in right ankle. Physical Exam: Swelling in right ankle is down. Left knee still puffy. Pain with flexion and extension, but no instability. Medical Decision: contusion left knee Plan: schedule MRI of knee and return after MRI taken. 9/2/04 Complaints: Knee is better. Still seeing Dr. Bertschinger for neck and shoulders. Some pain over the lateral aspect of the ankle. Still taking Bextra and Flexeril with Darvocet for pain. Physical Exam: Tender over medial collateral ligament. No effusion; no instability to anterior, posterior, or varus/valgus stress. Tender over knee but moving it much better. Still tender over lateral aspect of right ankle but drawer test is negative. Good inversion and eversion against resistance. Medical Decision: contusion left knee/ lateral sprain right ankle Plan: Continue same medicines; return in three to four weeks. 8/19/04 Complaints: Automobile accident. Pain in neck, both arms, both shoulders, left knee, and right ankle. Physical Exam: Able to get the right shoulder through a full ROM but can only forward flex the left shoulder to 90 degrees. Pain radiating down to both elbows and oddly the right side bothers her more than the left. Tender over both medial and lateral collateral ligaments. No instability to anterior, posterior, or varus/valgus stress. Some swelling over the lateral aspect of the right ankle; drawer test is negative. No deltoid tenderness; good inversion and eversion against resistance. Radiographs: views of left knee appear normal; three views of right ankle show some spurring. Medical Decision: traumatic cervical strain with aggravation of bilateral shoulder problems; contusion left knee; lateral sprain right ankle. Plan: Given Bextra, Darvocet, and Flexeril. Return in two weeks. 12

7/14/04 Complaints: Bextra and Skelaxin are helping. Has not done anything about her thyroid. Plan: Recommended she visit Shenandoah Community Health out of concern for thyroid and pursue medical card. Return in two weeks. 6/9/04 Complaints: Still taking Bextra. Pain in both shoulders but not ready for another injection. Able to abduct or forward flex to about 90 degrees. Both elbows are cracking but able to fully extend both elbows; appears to have normal flexion. No effusion. Ganglion cyst on dorsum of right wrist. Cold even in hot weather. Medical Decision: possible thyroid dysfunction Plan: return in two months; have thyroid checked 4/7/04 Complaints: left shoulder feeling better; right shoulder hurting. Using Bextra and Skelaxin as needed. Physical Exam: tender to palpation over tip of right acromion and has some subacromial crepitus Medical Decision: impingement right shoulder. Shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: return in a few months. 2/5/04 Complaints: pain in left shoulder worse than that in right. Unable to secure a medical card. Physical Exam: tender over tip of acromion on both shoulders. Pain with abduction and forward flexion above 70 degrees. Medical Decision: bilateral shoulder impingement syndrome. Shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: return in a few months. 11/23/03 Complaints: pain under right arm into rib area and posteriorly in periscapular area. Limited abduction and forward flexion of both shoulders. Moves right shoulder through a more normal ROM than the left. Appears to be gaining weight. Medical Decision: bilateral impingement syndrome Plan: Take Bextra and Skelaxin. Return in one month. 9/10/03 Complaints: pain in both shoulders; wants injection in right shoulder. Able to force right shoulder through a full ROM but has pain with abduction and forward flexion above 70 degrees. Motion limited on left. Medical Decision: impingement both shoulders. Right shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: given more Bextra. 13

6/3/03 Complaints: pain in both shoulders; Bextra giving some relief. Limited motion of left shoulder. Plan: left shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: return in a few months. 3/6/03 Complaints: fell on ice and landed on left shoulder. Pain with abduction and forward flexion; no crepitus to suggest anything broken. Medical Decision: post-traumatic impingement right shoulder. Right shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: given samples of Bextra; return if condition worsens. 11/15/02 Complaints: Patient asking for another corticosteroid injection. Pain in left shoulder with abduction and forward flexion above 70 degrees. Medical Decision: Impingement left shoulder. Left shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: given more samples of Bextra; return in a few months. 10/10/02 Complaints: impingement of both shoulders; feels like Bextra is helping. Plan: continue Bextra; return in one month 9/26/02 Complaints: discomfort; unable to exercise. Dark stools; stopped Vioxx, but became more symptomatic. Signs of impingement in both shoulders. Plan: return in two weeks 8/8/02 Complaints: pain in right shoulder similar to pain in left shoulder. Pain with abduction and forward flexion above 70 degrees. Bextra not helping as much as Vioxx. Medical Decision: impingement right shoulder. Right shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: given samples of Vioxx; return in six weeks. 7/9/02 Complaints: pain in both shoulders. Asked for right shoulder injection. Vioxx isn't helping her. Plan: given Bextra. 5/29/02 Complaints: can only abduct and forward flex to 90 degrees; very sensitive over the tip of the acromion. Left shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 14

1 cc of 1% Lidocaine. Plan: return in one month. 1/8/02 Complaints: Only able to abduct and forward flex to 90 degrees; tender over tip of the acromion. Medical Decision: chronic impingement left shoulder. Left shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: return in a few months. 9/11/01 Complaints: under stress. Subscribed medication from Dr. Rezaian. Medical Decision: left shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: return in a few months. 7/31/01 Complaints: Pain in shoulders, particularly left. Can only abduct or forward flex to 90 degrees. Subacromial crepitus. Plan: return in one month for injection in left shoulder. 6/10/01 called patient - MRI showed no definite rotator cuff tear. Plan: return in a few months if still in pain. 5/9/01 Complaints: shoulder pain Medical Decision: chronic impingement. Order MRI. Left shoulder infiltrated with 1% Lidocaine and injected with 40 mg DepoMedrol and 1 cc of 1% Lidocaine. Plan: given samples of Vioxx. Will call when have results. 2/28/01 Complaints: only able to abduct or forward flex left shoulder to 90 degrees. Slipped twice on ice in January; aggravated shoulder. Plan: given samples of Vioxx; return in one month. Medical Records and S.O.A.P Notes, Kerry V. Bertschinger, DC 8/17/04 - 1/10/05 (Tr. 247320) 8/17/04 Subjective: Pain worsening after automobile accident on 8/14/04. Pain in neck bilaterally; pain across tops of shoulders bilaterally; pain in arms bilaterally; tingling in upper arms bilaterally; light-headed; pain in ribcage bilaterally; pain in lower back bilaterally; aching in ankle on right; pain in shoulder bilaterally. Objective: muscle tightness in cervical spine bilaterally; decreased range of motion in cervical spine bilaterally; muscle tightness in upper thoracic spine bilaterally; decreased range of motion 15

in upper thoracic spine bilaterally; muscle tightness in thoraco-lumbar spine bilaterally; decreased range of motion in thoraco-lumbar spine bilaterally; muscle tightness in lumbo-sacral spine bilaterally; decreased range of motion in lumbo-sacral spine bilaterally; muscle tightness in hip joint bilaterally. Assessments: flare-ups in conditions Plan: return in two days Treatment: anterior adjustive procedures; specific posterior adjustive procedures administered. Cranial manipulation. Neck stretch. Diagnosis: neck sprain; brachial neuritis or radiculitis nos; lumbar sprain 8/19/04 Subjective: No change in pain in neck bilaterally; no change in pain across shoulders bilaterally; no change in pain and tingling in arms bilaterally; light-headedness has improved; no change in pain in ribcage bilaterally; no change in aching in ankle on right; no change in pain in shoulder bilaterally. Objective: muscle tightness in cervical spine bilaterally; decreased range of motion in cervical spine bilaterally; muscle tightness in upper thoracic spine bilaterally; decreased range of motion in upper thoracic spine bilaterally; muscle tightness in thoraco-lumbar spine bilaterally; decreased range of motion in thoraco-lumbar spine bilaterally; muscle tightness in lumbo-sacral spine bilaterally; decreased range of motion in lumbo-sacral spine bilaterally; muscle tightness in hip joint bilaterally. Assessment: continues to slowly improve Plan: return next week Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 8/23/04 Subjective: Pain in neck bilaterally is slightly improved; pain across shoulders bilaterally is very slightly improved; pain and tingling in arms bilaterally is very slightly improved; lightheadedness is very slightly improved; pain in ribcage bilaterally is very slightly improved; no change in pain in lower back bilaterally; no change in aching in ankle on right; pain in shoulder bilaterally is very slightly improved; pain in left knee. Objective: muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; no change in muscle tightness in thoraco-lumbar spine bilaterally; no change in decreased range of motion in thoraco-lumbar spine bilaterally; no change in muscle tightness in lumbo-sacral spine bilaterally; no change in decreased range of motion in lumbo-sacral spine bilaterally; no change in muscle tightness in hip joint bilaterally. Assessment: overall condition is slightly improved Plan: return in two days Treatment: specific posterior adjustive procedures 8/25/04 16

Subjective: Pain in neck bilaterally is very slightly improved; pain across shoulders bilaterally is very slightly improved; no change in pain and tingling in arms bilaterally; light-headedness is very slightly improved; pain in ribcage bilaterally is very slightly improved; no change in pain in lower back bilaterally; aching in right ankle is very slightly improved; pain in shoulder bilaterally is very slightly improved; pain in left knee is very slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is very slightly improved. Assessment: continues to slowly improve Plan: return in two days Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed. 8/26/04 Subjective: Pain in neck bilaterally is very slightly improved; pain across shoulders bilaterally is very slightly improved; pain and tingling in arms bilaterally are very slightly improved; no change in light-headedness; pain in ribcage bilaterally is very slightly improved; no change in pain in lower back bilaterally; aching in right ankle is very slightly improved; pain in shoulder bilaterally is very slightly improved; no change in pain in left knee. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is very slightly improved. Assessment: continues to slowly improve Plan: return next week Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 8/30/04 Subjective: Pain in neck bilaterally is slightly improved; no change in pain across shoulders bilaterally; no change in pain and tingling in arms bilaterally; light-headedness is very slightly improved; pain in ribcage bilaterally is very slightly improved; pain in lower back bilaterally is very slightly improved; no change in aching in right ankle; no change in pain in shoulder bilaterally; no change in pain in left knee. 17

Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is very slightly improved. Assessment: continues to slowly improve Plan: return in two days Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 9/1/04 Subjective: Pain in neck bilaterally is slightly improved; pain across shoulders bilaterally is slightly improved; pain and tingling in arms bilaterally are slightly improved; light-headedness is slightly improved; pain in ribcage bilaterally is slightly improved; pain in lower back bilaterally is slightly improved; aching in right ankle is very slightly improved; pain in shoulder bilaterally is slightly improved; pain in left knee is slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is very slightly improved. Assessment: continues to slowly improve Plan: return in one day Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 9/2/04 Subjective: Pain in neck bilaterally is very slightly improved; pain across shoulders bilaterally is very slightly improved; pain and tingling in arms bilaterally are very slightly improved; lightheadedness is slightly improved; pain in ribcage bilaterally is slightly improved; pain in lower back bilaterally is slightly improved; aching in right ankle is very slightly improved; pain in shoulder bilaterally is slightly improved; pain in left knee is very slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very 18

slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is very slightly improved. Assessment: continues to slowly improve Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 9/7/04 Subjective: Pain in neck bilaterally is very slightly improved; pain across shoulders bilaterally is very slightly improved; pain and tingling in arms bilaterally are very slightly improved; lightheadedness is very slightly improved; pain in ribcage bilaterally is very slightly improved; pain in lower back bilaterally is slightly improved; aching in right ankle is slightly improved; pain in shoulder bilaterally is slightly improved; pain in left knee is slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is slightly improved; muscle tightness in lumbo-sacral spine bilaterally is slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is slightly improved; muscle tightness in hip joint bilaterally is slightly improved. Assessment: continues to slowly improve Plan: return in two days Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 9/10/04 Subjective: Pain in neck bilaterally is very slightly worse; pain across shoulders bilaterally is very slightly worse; pain and tingling in arms bilaterally are very slightly worse; no change in light-headedness; pain in ribcage bilaterally is very slightly worse; pain in lower back bilaterally is very slightly worse; aching in right ankle is very slightly worse; pain in shoulder bilaterally is very slightly worse; pain in left knee is very slightly worse. Objective: Muscle tightness in cervical spine bilaterally is very slightly worse; no change in decreased range of motion in cervical spine bilaterally; muscle tightness in upper thoracic spine bilaterally is very slightly worse; decreased range of motion in upper thoracic spine bilaterally is very slightly worse; no change in muscle tightness in thoraco-lumbar spine bilaterally; no change in decreased range of motion in thoraco-lumbar spine; no change in muscle tightness in lumbosacral spine bilaterally; no change in decreased range of motion in lumbo-sacral spine bilaterally; muscle tightness in hip joint bilaterally is very slightly worse. Assessment: overall condition is very slightly worse Plan: return in three days Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed

19

9/13/04 Subjective: Pain in neck bilaterally is slightly improved; pain across shoulders bilaterally is slightly improved; pain and tingling in arms bilaterally are slightly improved; light-headedness is improved; pain in ribcage bilaterally is slightly improved; pain in lower back bilaterally is slightly improved; aching in right ankle is very slightly improved; pain in shoulder bilaterally is very slightly improved; pain in left knee is very slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is slightly improved; muscle tightness in lumbo-sacral spine bilaterally is slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is slightly improved; muscle tightness in hip joint bilaterally is slightly improved. Assessment: overall condition is slightly improved Plan: return in two days Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 9/15/04 Subjective: Pain in neck bilaterally is very slightly improved; pain across shoulders bilaterally is very slightly improved; pain and tingling in arms bilaterally are very slightly improved; lightheadedness is very slightly improved; pain in ribcage bilaterally is very slightly improved; no change in pain in lower back bilaterally; no change in aching in right ankle; no change in pain in shoulder bilaterally; no change in pain in left knee. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; no change in muscle tightness in thoraco-lumbar spine bilaterally; no change in decreased range of motion in thoraco-lumbar spine bilaterally; no change in muscle tightness in lumbo-sacral spine bilaterally; no change in decreased range of motion in lumbo-sacral spine bilaterally; no change in muscle tightness in hip joint bilaterally. Assessment: continues to slowly improve Plan: return in two days Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 9/17/04 Subjective: Pain in neck bilaterally is slightly improved; pain across shoulders bilaterally is slightly improved; pain and tingling in arms bilaterally are slightly improved; light-headedness is slightly improved; pain in ribcage bilaterally is slightly improved; pain in lower back bilaterally is very slightly improved; no change in aching in right ankle; pain in shoulder bilaterally is very slightly improved; no change in pain in left knee. 20

Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; no change in muscle tightness in lumbo-sacral spine bilaterally; no change in decreased range of motion in lumbo-sacral spine bilaterally; no change in muscle tightness in hip joint bilaterally. Assessment: continues to slowly improve Plan: return next week Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 9/21/04 Subjective: No change in pain in neck bilaterally; no change in pain across shoulders bilaterally; no change in pain and tingling in arms bilaterally; no change in light-headedness; no change in pain in ribcage bilaterally; no change in pain in lower back bilaterally; no change in aching in right ankle; no change in pain in shoulder bilaterally; no change in pain in left knee. Objective: No change in muscle tightness in cervical spine bilaterally; no change in decreased range of motion in cervical spine bilaterally; muscle tightness in upper thoracic spine bilaterally is very slightly worse; decreased range of motion in upper thoracic spine bilaterally is very slightly worse; no change in muscle tightness in thoraco-lumbar spine bilaterally; no change in decreased range of motion in thoraco-lumbar spine bilaterally; no change in muscle tightness in lumbo-sacral spine bilaterally; no change in decreased range of motion in lumbo-sacral spine bilaterally; no change in muscle tightness in hip joint bilaterally. Assessment: condition is same as last reported Plan: return in two days Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 9/29/04 Treatment: infrared treatment; therapy performed 10/7/04 Subjective: Pain in neck bilaterally is very slightly worse; pain across shoulders bilaterally is very slightly worse; pain and tingling in arms bilaterally are very slightly worse; no change in light-headedness; no change in pain in ribcage bilaterally; pain in lower back bilaterally is very slightly worse; no change in aching in right ankle; no change in pain in shoulder bilaterally; no change in pain in left knee. Objective: Muscle tightness in cervical spine bilaterally is very slightly worse; decreased range of motion in cervical spine bilaterally is very slightly worse; muscle tightness in upper thoracic spine bilaterally is very slightly worse; decreased range of motion in upper thoracic spine bilaterally is very slightly worse; muscle tightness in thoraco-lumbar spine bilaterally is very 21

slightly worse; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly worse; muscle tightness in lumbo-sacral spine bilaterally is very slightly worse; decreased range of motion in lumbo-sacral spine bilaterally is very slightly worse; muscle tightness in hip joint bilaterally is very slightly worse. Assessment: overall condition is slightly worse Plan: return in one day Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 10/8/04 Subjective: Pain in neck bilaterally is very slightly improved; no change in pain across shoulders bilaterally; no change in pain and tingling in arms bilaterally; no change in lightheadedness; pain in ribcage bilaterally is very slightly improved; pain in lower back bilaterally is very slightly improved; aching in right ankle is very slightly improved; pain in shoulder bilaterally is very slightly improved; pain in left knee is very slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is very slightly improved. Assessment: overall condition is slightly improved Plan: return next week Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 10/13/04 Subjective: Pain in neck bilaterally is very slightly improved; no change in pain across shoulders bilaterally; pain and tingling in arms bilaterally are very slightly improved; lightheadedness is very slightly improved; pain in ribcage bilaterally is very slightly improved; pain in lower back bilaterally is very slightly improved; aching in right ankle is very slightly improved; no change in pain in shoulder bilaterally; pain in left knee is very slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; no change in muscle tightness in upper thoracic spine bilaterally; no change in decreased range of motion in upper thoracic spine bilaterally; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is very slightly improved. Assessment: continues to slowly improve 22

Plan: return in two days Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 10/15/04 Subjective: Pain in neck bilaterally is very slightly improved; pain across shoulders bilaterally is very slightly improved; pain and tingling in arms bilaterally are very slightly improved; lightheadedness is very slightly improved; pain in ribcage bilaterally is very slightly improved; pain in lower back bilaterally is very slightly improved; aching in right ankle is very slightly improved; pain in shoulder bilaterally is very slightly improved; pain in left knee is very slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is very slightly improved. Assessment: continues to slowly improve Plan: return next week Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 10/22/04 Subjective: No change in pain in neck bilaterally; pain across shoulders bilaterally is very slightly worse; pain and tingling in arms bilaterally are very slightly worse; light-headedness is very slightly improved; pain in ribcage bilaterally is very slightly improved; pain in lower back bilaterally is very slightly improved; aching in right ankle is very slightly improved; pain in shoulder bilaterally is very slightly worse; pain in left knee is very slightly improved. Objective: Muscle tightness in cervical spine bilaterally is very slightly worse; decreased range of motion in cervical spine bilaterally is very slightly worse; muscle tightness in upper thoracic spine bilaterally is very slightly worse; decreased range of motion in upper thoracic spine bilaterally is very slightly worse; muscle tightness in thoraco-lumbar spine bilaterally is very slightly worse; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly worse; muscle tightness in lumbo-sacral spine bilaterally is very slightly worse; decreased range of motion in lumbo-sacral spine bilaterally is very slightly worse; muscle tightness in hip joint bilaterally is very slightly worse. Assessment: overall condition is slightly worse Plan: return in three days Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed

23

10/26/04 Subjective: Pain in neck bilaterally is slightly improved; pain across shoulders bilaterally is slightly improved; pain and tingling in arms bilaterally are slightly improved; light-headedness is improved; pain in ribcage bilaterally is slightly improved; pain in lower back bilaterally is slightly improved; aching in right ankle is slightly improved; pain in shoulder bilaterally is slightly improved; pain in left knee is slightly improved. Objective: Muscle tightness in cervical spine bilaterally is improved; decreased range of motion in cervical spine bilaterally is improved; muscle tightness in upper thoracic spine bilaterally is slightly improved; decreased range of motion in upper thoracic spine bilaterally is slightly improved; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly improved; decreased range of motion in lumbo-sacral spine bilaterally is very slightly improved; muscle tightness in hip joint bilaterally is slightly improved. Assessment: continues to slowly improve Plan: return in two days Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 10/28/04 Subjective: No change in pain in neck bilaterally; no change in pain across shoulders bilaterally; no change in pain and tingling in arms bilaterally; light-headedness is slightly improved; no change in pain in ribcage bilaterally; no change in pain in lower back bilaterally; aching in right ankle is very slightly improved; no change in pain in shoulder bilaterally; no change in pain in left knee. Objective: Muscle tightness in cervical spine bilaterally is very slightly improved; decreased range of motion in cervical spine bilaterally is very slightly improved; muscle tightness in upper thoracic spine bilaterally is very slightly improved; decreased range of motion in upper thoracic spine bilaterally is very slightly improved; no change in muscle tightness in thoraco-lumbar spine bilaterally; no change in decreased range of motion in thoraco-lumbar spine bilaterally; no change in muscle tightness in lumbo-sacral spine bilaterally; no change in decreased range of motion in lumbo-sacral spine bilaterally; no change in muscle tightness in hip joint bilaterally. Assessment: flare-ups seen in condition Plan: return next week Treatment: specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed 10/29/04 Subjective: Pain in neck bilaterally; pain across tops of shoulders bilaterally; pain in arm bilaterally; numbness in arm bilaterally; headache; dizzy/light-headed; pain in upper back bilaterally; stiffness in middle back bilaterally; pain in lower back bilaterally; pain in left knee; pain in right ankle; pain in hip bilaterally. Objective: Muscle tightness in cervical spine bilaterally; decreased range of motion in cervical spine bilaterally; muscle tightness in upper thoracic spine bilaterally; decreased range of motion 24

in upper thoracic spine bilaterally; muscle tightness in thoraco-lumbar spine bilaterally; decreased range of motion in thoraco-lumbar spine bilaterally; muscle tightness in lumbo-sacral spine bilaterally; decreased range of motion in lumbo-sacral spine bilaterally; muscle tightness in hip joint bilaterally; slight swelling on outside of right ankle. Diagnosis: neck sprain; sprain of unspecified site of shoulder and upper arm; sprain of unspecified site of knee and leg; ankle sprain 11/1/04 Subjective: Pain in neck bilaterally is very slightly worse; pain across tops of shoulders bilaterally is very slightly worse; no change in pain in arm bilaterally; no change in numbness in arm bilaterally; no change in headaches; no change in dizzy/light-headed complaint; no change in pain in upper back bilaterally; no change in stiffness in middle back bilaterally; pain in lower back bilaterally is very slightly worse; no change in pain in left knee; no change in pain in right ankle; pain in hip bilaterally is very slightly worse. Objective: Muscle tightness in cervical spine bilaterally is very slightly worse; decreased range of motion in cervical spine bilaterally is very slightly worse; muscle tightness in upper thoracic spine bilaterally is very slightly worse; decreased range of motion in upper thoracic spine bilaterally is very slightly worse; muscle tightness in thoraco-lumbar spine bilaterally is very slightly improved; decreased range of motion in thoraco-lumbar spine bilaterally is very slightly improved; muscle tightness in lumbo-sacral spine bilaterally is very slightly worse; decreased range of motion in lumbo-sacral spine bilaterally is very slightly worse; muscle tightness in hip joint bilaterally is very slightly worse; no change in slight swelling on outside of right ankle. Assessment: overall condition is very slightly worse Plan: return in two days Treatment: anterior adjustive procedures; specific posterior adjustive procedures; cranial manipulation; infrared treatment; therapy performed. 11/3/04 Subjective: Pain in neck bilaterally is very slightly improved; pain across tops of shoulders bilaterally is very slightly improved; pain in arm bilaterally is very slightly improved; numbness in arm bilaterally is very slightly improved; no change in headaches; no change in dizzy/lightheaded complaint; pain in upper back bilaterally is very slightly improved; stiffness in midd