DOI: 4/19/2016. Patient is a 58-year-old female non-food clerk who sustained injury while she was lifting a box when she experienced pain in her shoulder and back. Per OMNI, he was initially diagnosed with pain in unknown shoulder and neck.
Based on the chiropractic re-evaluation medical report dated 06/10/16, the patient complains of moderate pain to her neck with muscle ache paraspinally and radiation to the bilateral upper thoracic spine and shoulders.
On examination of the cervical spine, there is tenderness noted. Range of motion is decreased. Range of motion shows flexion and extension of 20 degrees, rotation of 45 degrees to the right and 35 degrees to the left and “LF” of 20 degrees to the right and 15 degrees
Based on the chiropractic re-evaluation medical report dated 06/10/16, the patient complains of moderate pain to her neck with muscle ache paraspinally and radiation to the bilateral upper thoracic spine and shoulders.
On examination of the cervical spine, there is tenderness noted. Range of motion is decreased. Range of motion shows flexion and extension of 20 degrees, rotation of 45 degrees to the right and 35 degrees to the left and “LF” of 20 degrees to the right and 15 degrees