Medical Case Summary

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DOI: 7/11/2015. Patient is a 49-year-old female parking attendant cashier who sustained a work-related injury to her neck, back, and bilateral shoulders and right shoulder when the vehicle she was riding was rear-ended. As per OMNI, the patient was diagnosed with cervical strain.
Per the IME report on 11/5/15, the patient received physical therapy at the rate of three times a week. The examiner notes that the patient has evidence of resolved cervical strain and right shoulder strain without objective evidence of continued disability. The patient has reached maximum medical improvement and does not require any further treatment per IME report.
As per office visit notes on 11/30/16, the patient continues to experience pain in her neck, lower back and shoulders. …show more content…
There is no improvement in her condition. She rates her pain as 5/10. She has received physical therapy (ultrasound, hot/cold most pack, manual massage therapy, therapeutic exercises and electrical muscle stimulation) over the past few weeks. She reports some relief of pain. Physical therapy has helped to loosen tight tissue, improve range of motion, strengthen muscles, increase joint flexibility and improve functional capacity. On examination, the patient has reduced range of motion on her neck with grade II tenderness/spasm over the paraspinals. Range of motion of the neck includes 30 degrees of flexion, 30 degrees of extension, and 20 degrees of lateral flexion on both sides. She has reduced range of motion on the bilateral shoulders with diffuse tenderness. Bilateral shoulder range of motion demonstrates 110 degrees of flexion, 20 degrees of extension, 110 degrees of abduction, and 20 degrees of adduction. Empty can test is positive in the shoulders. The patient also has reduced range of motion on her lower back with grade II tenderness/spasm over the lumbar paraspinals. Lumbar range of motion includes 60

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