Reason for Visit: s/p ESI X 9 Visits: Left Trapezius Strain
S: Aerotek TM completed total of 9 ESI visits. Reports improvement in her pain; 4/10; aching and tightness in her left infraspinats area. Denies any neck or upper back pain.
O: Assessment of cervical Neck, no atrophy, edema, or discoloration noted; denies any tenderness with palpation of cervical neck. Reports tenderness to infraspinatus with palpation, Full AROM and PROM, reports increased pain with ROM. Hawkins and Empty Can tests negative. No impairment of NVS, no impairment of CN. A: Left Trapezius Strain
P:
ESI x 2 week
Continue with Naproxen 220 mg, tab 1 tab by mouth every 12 hours
Acetaminophen 500 mg, tab, 2 tabs by mouth every 8 hours as needed for pain.
Biofreeze,
S: Aerotek TM completed total of 9 ESI visits. Reports improvement in her pain; 4/10; aching and tightness in her left infraspinats area. Denies any neck or upper back pain.
O: Assessment of cervical Neck, no atrophy, edema, or discoloration noted; denies any tenderness with palpation of cervical neck. Reports tenderness to infraspinatus with palpation, Full AROM and PROM, reports increased pain with ROM. Hawkins and Empty Can tests negative. No impairment of NVS, no impairment of CN. A: Left Trapezius Strain
P:
ESI x 2 week
Continue with Naproxen 220 mg, tab 1 tab by mouth every 12 hours
Acetaminophen 500 mg, tab, 2 tabs by mouth every 8 hours as needed for pain.
Biofreeze,