DOI: 8/12/2015. Patient is a 38-year old male journeyman carpenter who sustained injuries to his right cheek/lips/jaws and shoulders/upper back when he was struck by a hook that broke from come-along pin.
Based on the initial evaluation report dated 03/09/16, the patient complains of jaw pain aggravated by chewing, mouth pain aggravated by biting, face pain worse with chewing and right shoulder pain increased with lifting and overhead work.
The patient can perform the following activities but it always caused pain: lift heavy items; grasp items; sleep; and sit for prolonged periods.
He was currently taking Ibuprofen 800mg.As of this report, the patient has had 9 sessions of physical medicine.
On examination of the right shoulder, there was +3 spasm and tenderness to the rotator cuff muscles, upper
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Supraspinatus test was positive. Epworth Sleepiness Scale (ESS) score is 13/24.
Current medications include postconcussional syndrome, unspecified injury to face, teeth and supporting structures and right rotator cuff sprain.
Treatment plan includes acupuncture, multi-interferential stimulator purchase of ProStim 5.0 or equivalent and consultation with a dentist, psychologist and temporomandibular joint specialist.
IW was prescribed with ibuprofen.
Requested for a complete copy of the office visit report dated 03/09/16 as the 6th page is missing; however, no medical records received at the time of submission of the review to PA.
Current request is for 6 Acupuncture Therapy Sessions for the Right Shoulder and Jaw between 3/25/2016 and 5/24/2016. ort dated 03/09/16 as the 6th page is missing; however, no medical records received at the time of submission of the review to PA.
Current request is for 6 Acupuncture Therapy Sessions for the Right Shoulder and Jaw between 3/25/2016 and