DOI: 8/7/2015. Patient is a 44-year-old female assistant teacher who sustained a work-related injury when she fell and hit her head on a shelf which resulted to loss of consciousness after being pushed by a child. She was subsequently diagnosed with post-consciousness syndrome and neck strain.
Per the PT progress note dated 11/24/15, the patient has attended 4 sessions.
Based on the medical report dated 04/07/16, the patient presents with post-concussion symptoms. She reports that she is still having some neck pain, associated with concussion wax and wane. She is currently on amitriptyline 25-50 mg nightly for symptoms. Patient has residual headaches, cognitive deficits and symptom limited activities. Patient is also anxious and depressed.
Per the PT progress note dated 11/24/15, the patient has attended 4 sessions.
Based on the medical report dated 04/07/16, the patient presents with post-concussion symptoms. She reports that she is still having some neck pain, associated with concussion wax and wane. She is currently on amitriptyline 25-50 mg nightly for symptoms. Patient has residual headaches, cognitive deficits and symptom limited activities. Patient is also anxious and depressed.