Neck Pain Case Studies

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

Per medical report dated 11/24/15 by Dr. Cano, the patient is complaining of severe numbness in the right hand, tightness around the right worse than left hand. She also associates this with dropping items. She is unable to button her shirts or raise her arms up to her elbows. This is continuous all day long. Also, associated is severe low back pain with numbness, radiation, and muscle spasm in the thoracic area, and numbness and radiation down the right sciatic nerve with severe low back pain. She continued to work, sixteen-hour shifts, seven days a week. At this time, she is unable to function. She states that she has had 24 sessions of physical therapy that has definitely helped her.

S: TM missed 3 days of her ESI visit, related holidays, but she did continue with ice and plan of care as instructed at home. The TM reports her pain is 4/10, and the pain is described as aching type pain; the pain is intermittent. TM is currently taking Ibuprofen 800 mg tab, 1 tab 2 times a day and Acetaminophen 500 mg tab 2 tabs as needed for shoulder pain to manage her pain and it does help to decrease her pain to 2-3/10. TM denies any loss of ROM or sensation of the right arm; denies any tingling or numbness.

Per the Agreed Medical Re-Examination report dated 09/29/15, whole person impairment rating is 5%. Future medical care includes access to follow-up visits for monitoring of his condition for the next calendar year, with continued provision of pharmacological agents. Should patient experience a significant acute symptoms flare-up within the next calendar year, re-instatement of brief courses of traditional PT, acupuncture,

DOI: 6/12/2014. Patient is a 59-year-old right-handed male machine operator who sustained work-related injuries to his right arm, shoulder and neck when his right hand got caught in a mixer. As per office notes dated 9/6/16, the patient returns complains of continued neck pain with burning hot pain extending into the forearm down to the hand along the C6 and C7 distribution with numbness and tingling in the hand. The patient has undergone multiple medications, physical therapy, TEN both in physical therapy and home use. It was also noted that the pateint denies having cognitive behavioral therapy. The provider notes, that it would be appropriate as based on the history including postoperative right forearm fracture repair and forearm open reduction and internal fixation of the right distal radius that an additional surgery to the right arm and continue physical therapy, yet continues to have swelling

Based on the medical report dated 12/22/16, the patient was last seen on 10/13/16, and was recommended to have continued therapy. He has not had therapy secondary to insurance issues over the last month or so. He presents with ongoing right elbow pain status post cubital tunnel release and medial epicondylitis debridement, worsening with motion and activity, lifting, reaching, bending, upper extremity dressing, household

As per office notes dated 5/4/16, the patient is seen for bilateral elbow pain and bilateral wrist pain. She rates the pain as 3/10 with medication and 7/10 without medication. She is active for at least six hours a day and has energy to make plans. Her activity level has

On Primary Treating Physician’s Progress Report (PR-2) dated 08/11/2017, the patient presented with unchanged symptoms. His left-hand pain was rated at 8/10. and was described as constant and sharp. The pain was aggravated with certain movements and gripping. The

The patient was diagnosed with bursitis of the right shoulder, pain in right shoulder, and impingement syndrome of the right shoulder.

12/31/15 Progress Report described that the patient has cervical spine, right shoulder, and right wrist pain. She rates her cervical spine at 8/10-scale level and frequent; right shoulder pain at 8/10-scale level; and bilateral wrist pain at 6/10-scale level. The pain is frequent and improved since last visit. Rest and medications make the pain better. Weather

DOI: 1/19/2015. Patient is a 44-year-old female machine operator who sustained injury while lifting pieces of cardboard into the machine when she felt pain to both sides of her shoulders and neck. Per OMNI, she was diagnosed with cervical and shoulder sprain/strain.

A physical therapy evaluation dated 08/07/2017 indicated that the claimant had a right shoulder pain after a fall onto her elbow and knee at work on 06/28/2017. She stated that she will have a surgical intervention on her right shoulder. She rated the pain at 6-8/10. She was unable to reach above her right with the right upper extremity. Objective findings showed reduced right arm swing. It was noted that the claimant was unable to place the right hand behind the head or the ear. There was a noted atrophy of the right forearm. Therapeutic exercises, moist heat, TENS, cryotherapy, and patient

Per the doctor’s first report of occupational injury dated 02/19/16, the patient was prescribed with a tennis elbow strap, Relafen, Orthonesis analgesic gel, range of motion (ROM) exercise and ice/moist heat applications.

01/08/16 Progress Report noted that the patient sustained an initial injury in June 2014, due to a cumulative trauma. She sustained a new injury in January 2015 as well. She sustained an injury to her neck, right shoulder, right arm, and right knee. She had X-rays and MRI post injury. Her right knee swelled, but improved right after she received treatment for her right shoulder and right knee. She received PT and chiropractic treatment twice a week, medications and surgery to her right shoulder in May 2015. She has received no treatment for her neck or left shoulder. She has not received acupuncture. The patient presented today with complaints of occasional, mild to moderate, throbbing neck pain, stiffness and cramping. The physical exam of the cervical spine revealed positive tenderness to palpation of the cervical paravertebral muscles and bilateral trapezii. There is also a muscle spasm of the cervical paravertebral muscles. The cervical ROM is decreased and painful. Shoulder depression causes pain. The exam of the thoracic spine showed tenderness to palpation of the thoracic paravertebral muscles, right trapezius, T1-T2 spinous process, T2-T3 spinous process, right Rhomboid and right lateral

01/08/16 Progress Report noted that the patient continues to have head and neck pain and bilateral shoulder pain. There is also upper and middle back pain. The pains are described as stabbing, shooting, burning and painful. He hears a popping sound. The pain has become unbearable. The pain seems to be getting worse and the patient had to go to the ER several times because of it. He is quite depressed. The patient has become less active and outgoing due to pain. He is unable to do things at work and with the family like he used to before. He continues to take pain medication Norco for pain relief. He denies any adverse side effects with them. He takes it several times a day. It helps to dull and numb the pain symptoms. The pain has restricted and limited his ADLs. The patient had a surgery done on the right shoulder in 2007, after his injury. He had a QME on October 7, 2015 and an EMG/NCS done on June 4, 2008, which was normal according to the patient. MRI cervical spine showed disc herniation and foraminal compromise. The neck pain is associated with radiculopathy into the upper extremities, due