DOI: 4/24/2008. Patient is a 59-year old male chief manager who sustained a work-related injury while standing on a ladder and it collapsed on him causing him to fall backwards catching himself with his left arm. Per OMNI, he is status post left shoulder rotator cuff repair on 11/02/09 and manipulation under anesthesia on 06/14/10.
Based on the medical report dated 10/14/16, the patient has continued to do quite well, since the last visit although recently because of the cold, damp weather, he has had a little bit of increase in the aching pain in the neck, but this seems to be well controlled with current conservative care. He had been using ice packs and hot packs and daily stretching and strengthening exercises. He feels that it is currently
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All of this was consistent with his medication usage, and there does not appear to be any evidence of aberrant behavior. The patient reported is functional improvement score today at 75%, and his reduction in pain score at 70%.
His mood is significantly improved. He reports that he was previously very depressed and his outlook was very bleak in the past because he was very isolated and confined to bed most of the time. At this point, he has a very positive outlook about his future, and he has been more active socially with family and friends. At this point, he has become more self-sufficient, and after the facet joint injections, he was able to rotate the head enough where he is able to turn his head and be able to drive on his own. Overall, he has had significant functional improvement with a combination of the injection, therapies, and medications that have helped him manage his chronic pain after the injury that he suffered.
On examination, range of motion remains good in the neck with rotation to 60 degrees on the left and 30 degrees on the right. Extension of the neck is good at 60 degrees and flexion to one fingerbreadth of the