I am a 38-year-old male with confirmed cervical disc osteophyte complex at C5-C6 with severe…read morebilateral foraminal stenosis, documented on CT during a recent ER visit in which a neurosurgeon personally circled the findings and confirmed they were a problem. I traveled three hours and paid $250 out of pocket for a neurosurgical consultation at this practice. I communicated the following symptoms explicitly and in detail during my visit:
-- Frequent dropping of objects due to grip failure
-- Visible, reproducible muscle trembling triggered by holding my arms in certain positions -- a symptom I offered to demonstrate in the exam room
-- Bilateral weakness I described as approximately 100 times below my normal baseline, with complete inability to continue my prior workout regimen out of fear of worsening my condition
-- Progressive gait changes including left-sided foot drag and asymmetric spasticity on my right side
-- Balance impairment and instability that directly affects my ability to safely perform my job, which requires working at heights and in confined spaces
-- Difficulty eating, sleeping, sitting, standing, walking, and breathing
-- Muscle pain, weakness, and tightness throughout my entire body including my mid and lower back
-- Facial asymmetry and sensation changes in my face and head
-- Neck pain and stiffness
-- Symptoms that have been progressively worsening over at least three years with no relief from prior conservative treatment including physical therapy
The visit note documents the opposite of what I stated in nearly every category. Under Review of Systems, the following are all recorded as 'Not Present': neck pain, muscle pain, muscle weakness, trouble walking, unsteadiness, numbness, weakness, and paresthesias. The note explicitly states I 'deny any significant grip or dexterity issues, upper extremity weakness, lower extremity weakness, frequent falls, or balance impairment.'
I stated the opposite of every one of those things, explicitly and in detail, during the visit.
The physical examination consisted of the following: I was asked to squeeze the provider's fingers, lift my arms while he pushed down, and pull my arms while he pulled in the opposite direction. That was the entirety of the neurological examination performed.
Despite this, the visit note documents the following findings that were never assessed:
-- 'Normal Coordination' -- no coordination test was performed
-- 'Sensation intact throughout' -- no sensory testing was performed
-- 'Negative Hoffman's sign bilaterally' -- this test, which requires a specific finger flick maneuver to assess upper motor neuron integrity, was not visibly performed at any point during my visit
-- '5/5 strength bilaterally' -- documented despite my active and ongoing grip failure causing me to drop objects daily
-- No gait assessment was performed despite my reported progressive left-sided foot involvement and balance impairment
-- No Romberg test, no Babinski reflex, no Spurling's test, no Lhermitte's test, no fine motor assessment, no dynamometer grip measurement
A pain level of 10/10 was recorded in my chart. My pulse was 102. Despite this, the clinical narrative describes me as 'in no acute distress' with a 'relatively benign physical exam' and 'normal reflexes throughout.' These characterizations are internally inconsistent with the vital signs recorded in the same document.
The reproducible positional muscle trembling I described and offered to demonstrate is absent from the record entirely. This is not a clinical disagreement about interpretation -- it is a documented symptom that was neither assessed nor recorded.
I was referred to physical therapy for 6-8 weeks and told to obtain an MRI at an outside facility before returning, despite explicitly informing the provider that three years of prior conservative treatment including physical therapy provided no meaningful relief. This approach effectively deferred any surgical evaluation indefinitely while my symptoms continue to progress.
I work as a certified industrial inspector in environments requiring work at heights and in confined spaces. I explicitly told this provider that my balance impairment and weakness affect my ability to perform that work safely. The provider documented that I deny balance impairment. That inaccuracy in a legal medical document has direct occupational safety implications.
I have retained copies of all visit documentation. I am pursuing a formal second surgical opinion at another institution, a formal medical record amendment request under HIPAA, and will be filing a complaint with the Georgia Composite Medical Board.
I am sharing this review so that other patients presenting with serious progressive neurological symptoms understand that what they communicate in this office may not be accurately reflected in their medical record -- and that documented findings may exist for examinations that were never performed.
