April 21, 2010 Jane Doe Wonderful Insurance Company 123 Maple Street Anywhere, MI 60128
February 1, 2010
1. Neck Pain 2. Right Arm Pain
John Smith was seen in my office on February 1, 2010 for history, examination and treatment for the above chief complaints. At the time of the initial examination, the neck pain began on February 1, 2010 when he was cutting trees in his back yard. The patient recalls lifting the saw above his head when he felt a snap and then a sharp stabbing pain in the right upper shoulder and neck area. Pain began to radiate down to the right hand. The pain was described as a constant, severe pain which increased with any head rotation. The arm radiation was also constant. The patient wife had to drive him to the office. He had no other treatment up to this point.
Past history showed he had a motor vehicle accident two years before which caused increased neck pain but resolved fully with only minimal neck pain which was occasional. It responded well to neck exercises, home ice and massage.
The patient was last seen in this office on March 16, 2010. At that time the patient had minimal neck pain with no arm pain.
The initial examination on February 1, 2010 showed a normally developed Caucasian male in severe distress. He was unable to rotate his head in any plane. His wife needed to assist him with movement around the office.
Inspection of the neck showed a right convex curve with visible muscle spasms of the upper trapezius region.
Palpation of the neck and upper extremities showed severe muscle spasms with swelling of the levator scapula, trapezius and moderate spasms of the teres minor
Copyright 2010 by Dr. Kevin McNamee, DC, LAc. Please do not duplicate in any manner.