DOI: 9/22/2015. Patient is a 50-year-old female inspector who sustained an injury to her right shoulder while pulling a central unit down in assembly. As per OMNI, the patient is diagnosed with sprain to the right shoulder. She continues with opioids; home exercise program; medications including Ultracet, Nucynta and Voltaren Gel; and Transcutaneous Electrical Nerve Stimulation unit. As per medical report dated 12/09/15, the patient complains of neck and shoulder girdle pain. She is definitely improved. After her 4 acupuncture treatments, she no longer has stabbing pain in the back of her head or the headaches she had at one point. She feels the acupuncture allows her to be able to do her work more easily. She mentions of some swelling in her right hand that she gets occasionally, but this started before the acupuncture treatments. Flexeril definitely helps. Her pain rate is 5/10. Upon examination, shoulder range of motion is 140 degrees on abduction on the right and 180 degrees on the left. There is much less tenderness in the upper trapezius. She has full cervical flexion and extension with minimal pain and definitely a lot less than previously. Diagnoses are chronic cervical and shoulder girdle pain with history …show more content…
She is slightly better. She is still doing acupuncture therapy with Dr. Zhu. The right shoulder and the neck pain have significantly decreased, and admit relief in headaches with acupuncture therapy. She still has tightness and mild pain in the left shoulder. She is doing the acupuncture once weekly at this point. She works part time making sandwiches. She is unsure how much longer she will continue doing this kind of work as she feels that it is a bit much on her pain. Her right hand is still swelling. She did have a right upper extremity venous doppler done 12/18/2015, and it was negative for any blood flow