HISTORY: This patient is a (XX)-year-old male with pain to the upper thoracic back. The patient started to have pain while working with the chainsaw. The patient saw a chiropractor for six visits without resolution to his problems. The patient had a CAT scan, which was negative. The patient was taking anti-inflammatory medication and muscle relaxant with some improvement. However, he continued to have pain. The patient was diagnosed with strain to thoracic back.
SUBJECTIVE FINDINGS: At the time of the initial evaluation, the patient complained of a dull ache in the upper back at the level of 1 and 2 on a scale of 10. The patient states that the pain increases, especially, at the end of the day to a level 5-6 on a scale of 10. The patient is using heat at home. He also uses a hot tub with good pain relief.
OBJECTIVE FINDINGS: Cervical spine range of motion is within functional limit with pain to upper thoracic back with flexion and extension. Thoracic spine range of motion is within functional limits. Cervical spine strength is 5/5. Right lateral upper extremity range of motion is within functional limit and strength is 5/5. Palpation is positive over paraspinal muscles at the level of C7 through T3 with the right side being more than the left. Sensation is within normal limits. Biceps reflex test is 1+ bilaterally. Triceps reflex test, we were unable to elicit.
TREATMENT PLAN: We would like to see the patient for modalities, including moist hot packs, ultrasound, deep tissue massage, and for therapeutic exercises.
TREATMENT GOALS: Goals of physical therapy are:
1. Decrease pain to 0.
2. Improve function to normal.
SUBJECTIVE FINDINGS: This patient is a (XX)-year-old Hispanic female with pain in her lumbosacral spine on the right at the level of approximately L3-L4. She also has pain in her right shoulder. She states that the pain increases with activity and diminishes to zero, normally, with rest. The pain is intermittent and increases with certain motions and usually it takes a while to resolve. She is using Bextra p.r.n. and ibuprofen.
HISTORY: This patient had an insidious onset of pain approximately six months ago associated with stomach pain. She also began having pain in her right shoulder in May beginning with some swelling in her shoulder. The swelling subsided but some pain remains. The patient sought intervention from Dr. John Doe and was referred here.
OBJECTIVE FINDINGS: Observation: This patient appears a normally developed Hispanic female of stated age. She gaits and moves normally without splinting or with some posturing of her right shoulder. Palpation positive over the anterior surface of the shoulder, negative in the low back. Range of motion within normal limits with pain with right side bending. Resisted motion positive in right side bending. Shoulder range of motion limited in internal rotation to 25 degrees, all other motions within normal limits. Resisted motion positive in full flexion, abduction, and external rotation in a dependent position. Radiculopathy positive with pain radiating from the shoulder to just above the elbow.
TREATMENT PLAN: We would like to see the patient three times per week for modalities to decrease pain and exercise to increase strength and function.
TREATMENT GOALS: Goals and purpose of physical therapy intervention is to:
1. Decrease pain to zero.
2. Increase strength and function to normal.
3. Increase range of motion to normal.
