Dr. Pgdm's Treatment Plan

1146 Words Nov 20th, 2015 5 Pages
Dr. Lewellen’s treatment plan consisted of treatment twice a week for four to eight weeks, followed by treatment once a week for four to eight weeks, with re-evaluation at that time. He further recommended imaging of his lumbar spine, if his symptoms did not improve within three weeks. He also used corrective chiropractic adjustments, neuromuscular re-education, and therapeutic rehabilitative exercises to help stabilize the injured areas of his spine.

July 24, 2015 – July 29, 2015 – Physical Therapy: Mr. Rascon presented to Movement Dynamics three (3) more times during this period. Mr. Rascon’s complaints remained the same, however, his upper and lower back were his primary complaint. He continued to have functional limitations and reported going back to work on light duty with heavy lifting restrictions. The objective findings, diagnosis and program recommendations were unchanged at this time.

July 29, 2015 – Follow Up: Mr. Rascon presented to Synergy Health Partners for a follow-up visit. He had continued complaints of lower back, neck, wrist and right shoulder pain. Mr. Rascon reported going back to work on light duty and that he was still experiencing moderate to severe pain. He reported not being able to work as quickly or effectively as he did prior to the collision. He further reported feelings of irritability and depression.

Dr. Lichtenberg prescribed Tylenol #2 with Codeine in addition to Mr. Rascon’s previously prescribed Tramadol and Diazepam…
Open Document