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Neck Pain Case Summary

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DOI: 1/23/2016. Patient is a 21-year-old female housekeeper who sustained injuries to her head, neck and back when the elevator from the third floor dropped to the first floor. Per OMNI, she was initially diagnosed with neck and back sprain and headache.
Based on the progress report dated 03/29/16, the patient presents for follow-up of her cervical and lumbar strain. She feels slightly better. Neck pain is located posteriorly and associated with headache.
She has completed 8 PT sessions and has had functional improvement. She is using a brace/splint and is tolerating well.
Pain is rated as 5/10.
On examination of the cervical spine, there is tenderness at the left paraspinal. Palpation revealed left-sided muscle spasms.
On examination
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