To whom it may concern,

[Redacted] was evaluated in my office on 12/04/2025 for the purpose of a Defense Medical Examination today.  The claimant was informed that the examination was for evaluation purposes only; intended to address specific injuries or conditions as outlined by you.  This is not intended as a physician/patient relationship. The claimant was asked at the time of the examination not to engage in any physical movement beyond her personal limits, which may be painful or those which could cause harm or injury.

History Provided by the Patient:

[Redacted] states she was the passenger in a vehicle that was stopped at a red light.  When the light turned green, they proceeded through the intersection.  A police car coming from the LEFT side at high speed struck their vehicle in the driver’s rear side, spinning their car. She had no loss of consciousness.  She was able to exit the vehicle.  She was taken by a friend to an emergency room where she was evaluated and discharged.  At that time, she had pain in her neck and her low back.

Her treating physician has been Dr. Balu.  He referred her to physical therapy.  He also performed an injection in her lower back which was beneficial.  She states the injection was in 2024. She is not attending physical therapy at the present time.  She has no follow-up appointments scheduled with Dr. Balu.

Present Symptoms:

She has pain in her low back, worse on the LEFT side than the RIGHT.  It does not radiate into her lower extremities.  The pain is intermittent.  It is worse with standing, bending, and lifting.  Her pain improves with application of heat and OTC.  She is having no numbness or tingling at the present time.

Past Medical History:

None reported.

Surgical History:

None reported.

Current Medications:

None reported.

Allergies:

None known.

Social History

She is single.  She has three children at home.  She does not use tobacco products or drink alcoholic beverages.

Family HIstory:

None reported.

Occupational History:

Home Health Aide.

Prior Injuries:

Denies.

Present Activities:

She is independent with ADLs.  She needs help with certain chores such as mopping or lifting, taking out trash.  She is able to drive.  She is able to go grocery shopping.

Physical Examinations:

Height: 5 Feet 4 Inches

Weight: 200 pounds – X Reported □ Measured

Dominant Hand: RIGHT

Affect:	X Normal	□ Flat	□ Excitable
Appearance:	X Comfortable	□ Uncomfortable
Pain Behaviors:	X None	□ Mild	□ Moderate	□ Marked
Non-Physiologic Findings:	X None	□ Mild	□ Moderate	□ Marked

Cervical Examinations

Inspection 

Curves:	X Normal	□ Abnormal:
Posture:	X Normal	□ Abnormal:
Scars:	X Normal	□ Abnormal:

Palpation

Tenderness:	X Normal	□ Abnormal:
Muscle Spasm:	X Normal	□ Abnormal:
Muscle Guarding:	X None	□ Abnormal:

Cervical Compression*
X Negative       □ Positive:                                                                               

Cervical Range of Motion
Range of motion measurements were performed using an inclinometer. Consistent? □ No □ Yes

Motion	# 1	#2	# 3	Maximum
Flexion (Forward)	40º
Extension (Backward)	30º
Right Lateral	30º
Left Lateral	30º
Right Rotation	60º
Left Rotation	60º

Thoracic Examination

Inspection 

Curves:	X Normal	□ Abnormal:
Posture:	X Normal	□ Abnormal:
Scars:	X Normal	□ Abnormal:

Palpation

Tenderness:	X Normal	□ Abnormal:
Muscle Spasm:	X Normal	□ Abnormal:
Muscle Guarding:	X None	□ Abnormal:

Lumbar Examination

Inspection 

Curves:	X Normal	□ Abnormal:
Posture:	X Normal	□ Abnormal:
Scars:	X Normal	□ Abnormal:

Palpation

Tenderness:	X Normal	□ Abnormal: Mild LEFT lower lumbar tenderness.
Muscle Spasm:	X Normal	□ Abnormal:
Muscle Guarding:	X None	□ Abnormal:

Lumbar Range of Motion
Range of motion measurements were performed using an inclinometer. Consistent? □ No X Yes

Motion	# 1	#2	# 3	Maximum
Flexion (Forward)	60º
Extension (Backward)	10º with pain
Right Lateral	20º
Left Lateral	30º

Neurological Examination of Upper Extremity

Upper Extremity Deep Tendon Reflexes*
X Normal       □ Abnormal:                                                                               
Consistent?  □ No  X Yes

Reflex	Level	Right	Left
Biceps	C-5	1+	1+
Triceps	C-7	1+	1+
Brachioradialis	C-5-7	1+	1+

Upper Extremity Motor Examination*
X Normal       □ Abnormal:                                                                               
Consistent?  □ No  X Yes

Upper Extremity Sensory Examination*
X Normal       □ Abnormal:                                                                               
Consistent?  □ No  X Yes

Upper Extremity Examination

Inspection

Scars:	X Negative	□ Positive:
Deformity:	X Negative	□ Positive:
Discoloration:	X Negative	□ Positive:
Atrophy:	X Negative	□ Positive:
Swelling:	X Negative	□ Positive:

Palpation

Tenderness:

X Negative

□ Positive:

Shoulders

Inspection:	X Normal	□ Abnormal:
Impingement Signs:	X Normal	□ Abnormal:
Stability*:	X Normal	□ Abnormal:
Alignment/Deformity:	X Normal	□ Abnormal:
Palpation*:	X Normal	□ Abnormal:

Right Shoulder Motion                                                                              

Motion	Normal	# 1	# 2	# 3	Consistent?
Flexion	180º	180º			X Yes □ No
Extension	50º	50º			X Yes □ No
Adduction	40º	40º			X Yes □ No
Abduction	170º	170º			X Yes □ No
Internal Rotation	80º	80º			X Yes □ No
External Rotation	60º	60º			X Yes □ No

Left Shoulder Motion

Motion	Normal	# 1	# 2	# 3	Consistent?
Flexion	180º	180º			X Yes □ No
Extension	50º	50º			X Yes □ No
Adduction	40º	40º			X Yes □ No
Abduction	170º	170º			X Yes □ No
Internal Rotation	80º	80º			X Yes □ No
External Rotation	60º	60º			X Yes □ No

Neurological Examination of Lower Extremity

Lower Extremity Deep Tendon Reflexes*
X Normal       □ Abnormal:                                                                               

Reflex	Level	Right	Left
Knee	L-4	Diminished	1+
Ankle	S-1	Diminished	1+

Lower Extremity Motor Examination*
X Normal       □ Abnormal:                                                                               
Consistent?   □ No  X Yes

Lower Extremity Sensory Examination*
X Normal       □ Abnormal:                                                                               
Consistent?   □ No  X Yes

Straight Leg Raising
X Negative       □ Positive:                                                                               

Non-Organic Findings
X Normal       □ Abnormal:                                                                               

Review of Records:

State of Delaware Uniform Collision Report:
[Redacted] was front-seat passenger wearing a seatbelt, not ejected.  Airbag not deployed.  Refused treatment.

Bay Health Medical Center:
11/09/2023 – X-ray of lumbar spine is unremarkable.

11/09/2023 – X-ray chest, normal.

11/09/2023 – CT cervical spine, report is missing the conclusion.

09/23/2024 – X-ray of shoulder status post MVC, normal.

09/30/2018 – Emergency Room encounter for LEFT upper extremity numbness.  No history of trauma.  Assessment is paresthesia LEFT upper extremity.  The patient was discharged.

11/09/2023 – Emergency Room encounter after MVA.  She was a passenger.  Vehicle struck on driver’s side.  She did not hit her head.  No LOC.  Woke up today with soreness in multiple places.  Complains of neck and back pain.  Ambulating without assistance.  She had tenderness on the LEFT side of her neck and trapezial area.  No decreased range of motion.  Also tenderness in her LEFT thoracic and lumbar area.

06/15/2024 – Emergency Room encounter for fever, generalized aching, and headache.  On physical examination no cervical tenderness.  Review of systems negative for back pain.

09/23/2024 – Emergency Room encounter after MVC.  She was a restrained driver sitting at a stoplight and was rear-ended.  She has LEFT arm pain and LEFT-sided pain.

04/06/2024 – Emergency Room encounter for frontal headache.  Denies head injuries or trauma.  Impression: migraine.

Ganesh Balu:
11/17/2023 – Initial evaluation after MVA.  Cervical, thoracic, and lumbar pain.  Assessment is cervical facet syndrome, cervical radiculopathy, thoracic facet joint syndrome, lumbar facet joint syndrome.  Compounded cream provided.  In-house therapy is recommended.

12/01/2023 – Follow-up appointment for in-house therapy.

12/06/2023 – Follow-up physical therapy.  Given a home exercise program.

01/31/2024 – Follow-up physical therapy.

05/21/2024 – Cervical pain 90 percent resolved.  Low back brace prescribed.

09/30/2024 – Return for follow-up after several months.  Continues to have low back pain, neck and mid back have improved.  Started on muscle relaxant.  In-house therapy recommended.

10/08/2024 – Operative Note.  Procedure: L3-S1 facet joint injections on the LEFT.

10/14/2024 – Cervical/thoracic pain 90 percent resolved.  Lumbar pain 80 percent resolved.

11/06/2024 – A narrative report reviewing treatment his diagnosis for cervical, thoracic, and lumbar facet syndrome.  He indicates the treatment he has given has been reasonable and necessary.  He indicates she may require further treatment including injections and that her condition may worsen.

03/10/2025 – A follow-up evaluation due to continued symptoms with more or less the same conclusions.

Conclusions:

Diagnoses Causally Related To The Mva On 11/08/2023:

1. Cervical sprain.
2. Lumbar sprain.

Diagnoses Unrelated To Motor Vehicle Accident On 11/08/2023:

1. LEFT shoulder condition is related to a subsequent motor vehicle accident.

Based on my examination today, review of the available medical records, and within a reasonable degree of medical probability, the following are my responses to your interrogatories regarding Ms. Latoya Shanice Perry.

There are no pre-existing conditions that influence the claimant’s present diagnosis.

The plaintiff is no longer in treatment for injury sustained on 11/08/2023, nor is she taking any medications.

No additional testing or medical treatment is reasonable or necessary that would be causally related to the motor vehicle accident on 11/08/2023.

[Redacted] diagnosis is good for return to normal activities without restriction.

[Redacted] sustained no permanent injury as a result of the motor vehicle accident on 11/08/2023.

[Redacted] did not demonstrate any symptom magnification.

[Redacted]has reached maximum medical improvement.

[Redacted] is capable of working without restrictions.  Her alleged injuries do not prevent her from everyday activities.

I hereby attest that I have personally reviewed all of the documents presented to me and that the opinion in this report is my own.  I have a scope of licensure that typically manages the medical contention, procedure, treatment, or issue under review for this specific case.  I have current, relevant experience and/or knowledge to render a determination for this case.  To the best of my knowledge, I have not been involved with a specific episode of care prior to the referral of this review.  I have no relationship, affiliation or conflict of interest with the covered person or covered person’s authorized representative whose treatment is the subject of this review.  I have no material professional, familial, or financial conflict of interest with the referring entity, the insurance issuer, or group health plan that is the subject of this review; or any officer, director, or management employee of the insurance issuer that is the subject of this review.  I have no material professional, familial or financial conflict of interest with the health care provider, the health care provider’s medical group or independent practice Association recommending the health care service or treatment that is the subject of this review, the facility at which the recommended health care service or treatment would be provided or the developer or manufacturer of the principal drug, device, procedure or other therapy being recommended for the covered person who is the subject of this review. I have no incentive to promote the use of any services which may be associated with the claim that is the subject of this review.  As an independent reviewer, I have not and will not accept compensation for this or any other independent review activities that is dependent in any way on specific outcome of this case or other cases.  It is important to point out that this review is meant to be of assistance in the case evaluation process and is not intended to establish the patient/doctor relationship.  My opinion is based on the information available for review and held to a reasonable degree of medical probability except when specifically stated otherwise.

Sincerely,
Jonathan L. Kates, M.D.