I conducted and independent medical examination of plaintiff. On exam, she is very pleasant and cooperative. She looks her stated age. Her speech content and thought processes are normal. Her cognitive status is perfect. She has a supple neck. She has full back motion without straight leg raising pain. She has full shoulder motion. She has normal strength in her arms and legs. Cranial nerves II, III, IV, V, VI, VII, VIII, IX, X, XI and XII were examined and were normal. Her palate elevates and her tongue is midline. Her gait is normal. Her cerebellum and balance as tested by finger-to-nose and heel-to-shin is normal. She has symmetrical reflexes, none of which are pathologic.
I reviewed actual CT scans of the head and neck, and the actual MRI scans of the brain and cervical spine performed after the accident. I agree with the interpretations. There are very minor degenerative changes on the cervical spine MRI but no disc herniation or surgical condition. The brain MRI and CT are both normal.
Based on the history provided to me, plaintiff sustained a whiplash-type injury. She was observed for 24 hours in the hospital. She underwent chiropractic treatment and underwent a few months of outpatient physical therapy, which she says was helpful to her. She is no longer in need of further physical therapy or workup. I believe her main injury was a cervical strain which did produce some headache and some pain in her neck and shoulders. The accident caused no structural damage based upon careful review of her CT and MRI scans, as well as the electromyography EMG/NCV studies. Her examination today was normal. I believe that plaintiff has fully recovered from any and all affects of the car accident. It does not appear that any of her activities, including work, are limited in any way by the accident in question. The treatment to date was reasonable and necessary.