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Chiropractic Case Studies

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This is a 53-year-old female with a 11/03/2015 date of injury, due to repetitive lifting.

01/14/16 Progress Report noted a follow-up visit for an injury sustained on 11/03/15. The patient is 55 % better. There is decreased in pain and increase in the ROM of the neck. The patient stated that she fees that she could tolerate full duty. The treatment was followed and tolerated. He is currently on modified duty. She has completed 6 visits of Chiropractic treatment. She is tolerating her current medications. The right-sided neck pain was 3/10-scale level. She described the pain as sharp and minimal. She denies any pain in her arms. There is no numbness and tingling in the arms. The patient denies any weakness of the upper extremities. The patient …show more content…
Patient’s pain has plateaued. She feels that she cannot tolerate full-duty. She is currently on modified duty. The treatment was followed and tolerated. The patient has completed 5 visits of Chiropractic. The neck pain was 0-3/10-scale level. She described the pain as sharp, minimal, and occasional. Movement exacerbates the symptoms. There is also pain in the arms and right shoulder. There is no numbness and tingling in the arms. The patient denies any weakness of the upper extremities. The patient states that there is no pain with the motion of the neck. The patient does not have any restrictions in the neck motion. The patient also has 3/10-scale level thoracic pain. The pain is dull, mild, and intermittent. Heavy use exacerbates the pain. Current medications: Etodolac and cyclobenzaprine. Musculoskeletal exam showed no neck stiffness in the neck and no tenderness in the posterior area. There is tenderness in paracervical and trapezius. Spasms were note din the trapezius. Cervical compression and distraction tests for nerve root compression were negative. ROM of the neck is full. There was tenderness of the thoracolumbar exam. There are no spams in the lumbar area. There is no tenderness of the paravertebral muscles. Patrick-Faber test and Extensor halluces longus test were negative. There are no restrictions in the ROM of the back. Sensations to light touch and pin prick were intact in all the dermatomes of the upper and lower extremities. Plan: Expected MMI date is 12/31/15. She is improving, continue medications, light duty, heat therapy, stretching exercises, and continue Chiro 6 more ordered today. Follow-up is in 7

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