Corey Kline

 
 20/09/12 FRI 01:07 PM NBH OCCUPATIONAL HEALTH 
 FAX NO. 707 xxx xxx
 P. 62 
 Page 1 of 62 
 OCCUPATIONAL HEALTH 
 A NorthBay Affiliate 
 I have not violated Labor Code 139.3 and the contents of the report and bill are true and correct to the best of my knowledge. 
 Signed this date, Solano County, California 
 INITIAL REPORT 
 CHIEF COMPLAINT: Back pain. 
 HISTORY OF PRESENT ILLNESS: This 26-year-old man is referred from the 
 emergency department where he was seen two days ago. He was x-rayed in the 
 department and given medications for spasm. His examination in the emergency 
 department showed no motor loss. 

 PHYSICAL EXAMINATION: 
 He is awake and alert, moves very slowly onto the exam table and his motions on the 
 table demonstrate that there is stiffness and spasm. His vital signs are normal. The patient 
 has somewhat decreased lumbar lordosis to palpation and observation. There is some 
 spasm in the left lumbar paraspinals. In the supine posture, his straight leg raise is 60 
 degrees bilaterally and the Lasegue's is negative bilaterally. He has full motor in the 
 lower extremity. His deep tendon reflexes are 2+, full patellar and calcaneal reflexes 
 DATE: 20/09/12
 PATIENT: Bethany Ingram
 DOB: 98/12/22
 EMPLOYER: CHEVY'S FAIRFIELD 
 DOI: 17/06/15
 
