Symptoms And Treatment Of Medical Records

1568 Words7 Pages
This is a 56-year-old female with a 1-11-2015 date of injury, when he tripped over some cables and fell. 01/08/16 DWC Form RFA for Acupuncture; X-Rays C/S, T/S, Bilateral shoulders; Referrals FCE, Ortho surgeon, pain management; medical records are requested; and re-evaluate. 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
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