| 10/18/2022 |
Patient Complaints & Limitations: Patient was involved in an electric bicycle incident, where he collided with a vehicle and fell on his right shoulder. He denied any neck or back pain, chest pain, dizziness, weakness, shortness of breath, abdominal pain, nausea or vomiting.(Exhibit 2-p.3) |
| 10/18/2022 |
Diagnostic Tests & Findings From This Visit: Physical examination revealed a deformity in the patient's right shoulder. A secondary examination revealed no additional obvious injuries.(Exhibit 2-p.3) |
| 10/18/2022 |
Medical Diagnoses: Patient was diagnosed with a shoulder injury following an electric bicycle incident.(Exhibit 2-p.3) |
| 10/18/2022 |
Treatments Administered During This Visit: Patient was given Fentanyl per protocol.(Exhibit 2-p.3) |
| 10/18/2022 |
Referrals: Patient was transported to Anduin Medical Center of Gondor for further care.(Exhibit 2-p.3) |
| 10/18/2022 |
Statements of Causality: Patient's shoulder injury was caused by a collision with a vehicle while he was riding an electric bicycle.(Exhibit 2-p.3) |
| 10/18/2022 |
All Other Information: The patient was alert and oriented at the scene and during transport. His oxygen saturation remained above 94% on room air.(Exhibit2- p.3) |
| 10/18/2022 |
Patient Complaints & Limitations: Patient presented with constant right shoulder pain following a motorized bicycle accident.(Exhibit3-p.60) |
| Patient experienced pain with abduction of the right shoulder.(Exhibit3-p.62) |
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| 10/18/2022 |
HPI & Prior Medical History: Patient has a past medical history of asthma and bipolar 1 disorder.(Exhibit3-p.60) |
| Patient is a smoker and consumes 0.5 packs per day.(Exhibit3-p.60) |
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| He has undergone hernia repair in the past.(Exhibit3-p.60) |
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| 10/18/2022 |
Diagnostic Tests & Findings From This Visit: X-ray of the right shoulder revealed acromioclavicular separation.(Exhibit3-p.63) |
| X-ray of the left shoulder was unremarkable.(Exhibit3-p.63) |
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| Physical examination revealed mild tenderness over the right acromioclavicular joint.(Exhibit3-p.63) |
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| 10/18/2022 |
Medical Diagnoses: Patient was diagnosed with right shoulder pain and acromioclavicular separation.(Exhibit3-p.63) |
| 10/18/2022 |
Treatments Administered During This Visit: Patient's right arm was placed in a sling.(Exhibit3-p.62) |
| Patient was prescribed Hydrocodone-Acetaminophen and Ibuprofen for pain management.(Exhibit3-p.63) |
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| 10/18/2022 |
Treatment Recommendations: Patient was advised to follow up with his primary care provider or a specialist.(Exhibit3-p.64) |
| Bilateral acromioclavicular X-rays were recommended for comparison.(Exhibit3-p.68) |
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| 10/18/2022 |
Treatment Objectives & Goals: The goal is to manage the patient's pain and monitor the acromioclavicular separation for any complications.(Exhibit3-p.63) |
| 10/20/2022 |
Patient Complaints & Limitations: Patient presents with severe back and shoulder joint pain following a motorized bicycle incident.(Exhibit 1 - p.1) |
| The patient also reports lower back pain, which could be exacerbated by the injury.(Exhibit 1 - p.5) |
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| 10/20/2022 |
HPI & Prior Medical History: Patient has a history of low back pain.(Exhibit 1 - p.5) |
| 10/20/2022 |
Past Tests & Findings: X-ray of the right shoulder shows acromioclavicular separation. X-ray of the left shoulder is unremarkable.(Exhibit 1 - p.4) |
| 10/20/2022 |
Medical Diagnoses: Patient was diagnosed with dislocation of the right acromioclavicular joint following the incident.(Exhibit 1 - p.4-5) |
| 10/20/2022 |
Past Treatments: Patient was discharged from the emergency room with Ibuprofen 800 mg and Hydrocodone-Acetaminophen 5 mg/325 mg for pain relief.(Exhibit 1 - p.4) |
| 10/20/2022 |
Treatments Administered During This Visit: Patient was prescribed Ibuprofen and Baclofen for pain relief.(Exhibit 1 - p.5) |
| 10/20/2022 |
Treatment Recommendations: Patient was advised to follow up with his primary care provider for an orthopedic referral. (Exhibit 1 - p.5) |
| Referrals: An orthopedic referral was ordered. (Exhibit 1 - p.5) |
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| Statements of Causality: The patient's injuries and current condition are a result of a motorized bicycle accident. (Exhibit 1 - p.1) |
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| All Other Information: Patient was advised on lifestyle education regarding diet, exercise, and nicotine cessation (Exhibit 1 - p.6) |
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| 11/10/2022 |
Patient Complaints & Limitations: Patient experiences right shoulder pain, right elbow pain, bilateral knee pain, low back pain, and right ankle pain. He has difficulty with stairs due to knee pain and experiences pain and numbness in the medial aspect of the ankle. He also has persistent mid-to-low back pain and difficulty sleeping due to chronic discomforts in the shoulder and lower back. The patient has been unable to work since the collision. (Exhibit 5 - p.1 - 2) |
| Patient is experiencing chronic pain and is likely in need of right shoulder surgery with AC joint reconstruction and repair of the coracoclavicular ligaments. (Exhibit 5 - p.2) |
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| 11/10/2022 |
HPI & Prior Medical History: Patient was involved in a bicycle incident on 10/18/2022, where he was struck by an automobile. He was flung over 15 feet and hit the ground, resulting in a total loss of his bike. He was taken to the emergency room where X-rays were obtained showing separation in the acromioclavicular joint of his right shoulder. A primary care physician has treated him since the incident. He has a history of lower back pain. (Exhibit 5 - p.1) |
| 11/10/2022 |
Past Tests & Findings: X-rays of the patient's right shoulder on 10/18/2022 showed separation in the acromioclavicular joint. No fractures were seen. (Exhibit 5 - p.1) |
| 11/10/2022 |
Medical Diagnoses: Patient has been diagnosed with right shoulder acromioclavicular joint separation, right elbow strain, bilateral knee strains, low back strain, and right ankle strain. (Exhibit 5 - p.2) |
| 11/10/2022 |
Past Treatments: The patient has been prescribed medications, including Cyclobenzaprine, Ibuprofen, and Tramadol for pain management. (Exhibit 5 - p.2) |
| 11/10/2022 |
Treatment Recommendations: An MRI has been ordered for the patient's right shoulder, right elbow, bilateral knees, and lumbar spine. Consideration will be made for an MRI of the ankle. (Exhibit 5 - p.2) |
| Patient is recommended to follow up in the next few weeks for a review of injuries. Right shoulder surgery with acromioclavicular joint reconstruction and repair of the coracoclavicular ligaments is likely needed. (Exhibit 5 - p.2) |
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| 11/10/2022 |
Treatment Objectives & Goals: The goal is to manage and alleviate the patient's chronic pain, potentially through surgical intervention. (Exhibit 5 - p.2) |
| 11/10/2022 |
Statements of Causality: The patient's current medical conditions and pain are a result of a bike accident where he was struck by an automobile. (Exhibit 5 - p.1) |
| 11/22/2022 |
Patient Complaints & Limitations: Patient experienced pain extending from the right shoulder to hand, swelling, mass, or lump in the area, stiffness of the joint, and decreased range of movement. (Exhibit 6 - p.3) |
| 11/22/2022 |
HPI & Prior Medical History: Patient was involved in a motor vehicle accident on 10/18/22. (Exhibit 6 - p.3) |
| 11/22/2022 |
Diagnostic Tests & Findings From This Visit: MRI of the right shoulder was performed. Findings include an intraosseous cyst within the humeral head/neck junction, thickening of the infraspinatus tendon with intermediate signal change, acromioclavicular joint separation injury, and fluid within the subacromial/subdeltoid bursa suggestive of bursitis. (Exhibit 6 - p. 3 - 4) |
| 11/22/2022 |
Medical Diagnoses: Diagnosed with effusion, stiffness, pain in the right shoulder, acromioclavicular separation injury, and tendinosis of the infraspinatus tendon. (Exhibit 6 - p. 1, 4) |
| 11/22/2022 |
Statements of Causality: The patient's symptoms and findings are likely due to the motor vehicle accident. (Exhibit 6 - p. 3) |
| 12/13/2022 |
Diagnostic Tests & Findings From This Visit: Patient had a normal variant of ECG. Patient is medically cleared for surgical intervention. (Exhibit 7 - p. 4) |
| 01/03/2023 |
Only bills without corresponding medical records. (Exhibit 9 - p. 1) |
| 01/03/2023 |
Patient Complaints & Limitations: A 43-year-old male patient with significant discomfort in his right shoulder due to injury. The patient has failed conservative treatment and wishes for surgical intervention. (Exhibit 8 - p. 2) |
| 01/03/2023 |
Medical Diagnoses: Preoperative diagnoses include right shoulder acromioclavicular joint separation, internal derangement, and bursitis. (Exhibit 8 - p. 1) |
| Postoperative diagnoses include right shoulder acromioclavicular joint separation, grade 4 chondromalacia of humeral head, labral tear, synovitis, and subacromial bursitis. (Exhibit 8 - p. 1) |
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| 01/03/2023 |
Treatments Administered During This Visit: Procedures performed include right shoulder open acromioclavicular joint reconstruction with allograft, arthroscopy with microfracture of the humeral head, extensive debridement of the glenohumeral joint with debridement of type 1 SLAP tear and anterior labral tear, subacromial decompression, partial synovectomy, and open distal clavicle excision. (Exhibit 8 - p. 4) |
| 01/03/2023 |
Treatment Recommendations: Patient was instructed to remain in a sling for four weeks and will follow up in approximately two weeks. (Exhibit 8 - p. 6) |
| 02/15/2023 |
Patient reports stiffness and limited range of motion in the right shoulder following surgical intervention for an acromioclavicular joint sprain. This limits his independence with activities of daily living and work-related tasks. (Exhibit 11-p.3) |
| 02/15/2023 |
HPI & Prior Medical History: Patient has a history of anxiety, depression, asthma, allergies, and smoking. He was involved in a bicycle incident on October 18th, 2022, which resulted in an acromioclavicular joint sprain requiring surgical intervention. (Exhibit 11-p.1) |
| 02/15/2023 |
Past Tests & Findings: Physical examination of the right shoulder revealed no abnormalities. However, there was hypomobility in the glenohumeral joint and scapular passive mobility within functional limits in all planes. (Exhibit 11-p.2) |
| 02/15/2023 |
Medical Diagnoses: Patient was diagnosed with an acromioclavicular joint sprain following a bicycle incident. (Exhibit 11-p.1) |
| 02/15/2023 |
Past Treatments: Patient underwent surgical intervention for the acromioclavicular joint sprain on January 3, 2023. (Exhibit 11-p.1) |
| 02/15/2023 |
Treatments Administered During This Visit: During this visit, the patient performed range of motion exercises and stabilization training. (Exhibit 11-p.2) |
| 02/15/2023 |
Treatment Recommendations: It is recommended that the patient attend rehabilitative therapy for 2 visits a week with an expected duration of 6 weeks. The plan of care includes patient education, a home exercise program, manual therapy techniques, modalities as needed, neuromuscular re-education, self-care and home management, stretching and flexibility activities, therapeutic activities, and therapeutic exercises. (Exhibit 11-p.4) |
| 02/15/2023 |
Treatment Objectives & Goals: The goal of the treatment is to decrease his pain, improve his function, improve his motor control, increase his range of motion, increase his strength, and allow him to return to work. Specific goals include achieving range of motion improvements in his right shoulder, improving his upper right extremity strength, and improving his ability to complete his activities of daily living. (Exhibit 11 - p.5-6) |
| 02/15/2023 |
Statements of Causality: The patient's current shoulder issues are a result of the bicycle incident he was involved in on October 18th, 2022. (Exhibit 11-p.1) |
| 02/15/2023 |
All Other Information: The patient is not currently working and has been identified as a fall risk. He was provided with a written home exercise program and his overall rehabilitation potential is good. (Exhibit 11-p.1) |
| 02/17/2023 |
Patient's main complaint is stiffness in the right shoulder. He has difficulty reaching away from the body, overhead and behind, and experiences 1-3 night disturbances. (Exhibit 11-p.8) |
| 02/17/2023 |
HPI & Prior Medical History: Patient has a history of anxiety, depression, asthma, allergies, and smoking. He was involved in a bicycle incident on October 18th, 2022, which resulted in an acromioclavicular joint sprain requiring surgical intervention. (Exhibit 11-p.8) |
| 02/17/2023 |
Diagnostic Tests & Findings From This Visit: Objective examination of the right shoulder showed no abnormalities (Exhibit 11-p.8). Clearing examination of the cervical spine showed no abnormalities (Exhibit 11-p.8). Muscle testing of the right shoulder showed limited abduction and flexion, and increased external and internal rotation (Exhibit 11-p.9) |
| 02/17/2023 |
Medical Diagnoses: Patient was diagnosed with an acromioclavicular joint sprain following a bicycle incident. (Exhibit 11-p.8) |
| 02/17/2023 |
Past Treatments: Patient underwent surgical intervention for his AC joint sprain on 1/3/2023. (Exhibit 11-p.8) |
| 02/17/2023 |
Treatments Administered During This Visit: During this visit, the patient performed range of motion exercises and stabilization training. (Exhibit 11 - p.9) |
| 02/17/2023 |
Treatment Recommendations: Continue with the current program. (Exhibit 11 - p.10) |
| 02/17/2023 |
Treatment Objectives & Goals: The goal of rehabilitation is to minimize loss of function and improve shoulder range of motion, strength, and joint mobility. (Exhibit 11 - p.8) |
| 02/17/2023 |
Statements of Causality: The patient's current shoulder issues are a result of the bicycle incident he was involved in on October 18th, 2022. (Exhibit 11 - p.8) |
| 02/21/2023 |
Patient's main complaint is stiffness in the right shoulder. He reports being sore the day before but feeling better on the day of the evaluation. He has difficulty reaching away from the body, overhead and behind, and experiences 1-3 night disturbances. (Exhibit 11 - p.11) |
| 02/21/2023 |
HPI & Prior Medical History: Patient has a history of anxiety, depression, asthma, allergies, and smoking. He was involved in a bicycle incident on October 18th, 2022, which resulted in an acromioclavicular joint sprain requiring surgical intervention. (Exhibit 11 - p.11) |
| 02/21/2023 |
Diagnostic Tests & Findings From This Visit: An objective examination of the right shoulder showed no abnormalities. (Exhibit 11 - p.11). Clearing examination of the cervical spine showed no active or passive range of motion and no palpation. (Exhibit 11 - p.11) Palpation of the right shoulder showed hypomobility in the glenohumeral joint, more on the right than left. Scapular passive mobility was within functional limits in all planes. It was inconclusive if the end feel for passive external rotation of the right shoulder was limited by pain or true capsular end feel. (Exhibit 11 - p.11) The range of motion of the right shoulder was limited. (Exhibit 11 - p.11 - 12) |
| 02/21/2023 |
Treatments Administered During This Visit: During this visit, the patient performed range of motion exercises and stabilization training. (Exhibit 11 - p.12) |
| 02/21/2023 |
Treatment Recommendations: Continue with current program. (Exhibit 11-p.13) |
| 02/21/2023 |
Treatment Objectives & Goals: The goal of the treatment is to minimize loss of function. (Exhibit 11 - p.11) |
| 02/21/2023 |
Statements of Causality: The patient's right shoulder pain and stiffness are likely due to the motor vehicle accident he was involved in. (Exhibit 11 - p.11) |