Pain Management Case Summary

DOI: 6/27/2015. Patient is a 32-year old male field technician who sustained injury when he was rear ended while he is in a parked truck/vehicle. Per OMNI, he was initially diagnosed with neck and back pain.
Based on the latest medical report by Dr. Tolat dated 01/26/16, the patient complains of increase in neck pain which is now a 6/10 in intensity. He notes ongoing weakness of both upper extremities. He complains of increased middle-back pain and low back pain which is now a 7/10 in intensity.
He last attended physical therapy on 10/20/15. He was last seen on 11/10/15, at which time MD felt he had plateaued and reached maximal medical benefit and therefore formal physical therapy was discontinued.
He received two lumbar epidural steroid injection treatments.
He is currently taking Motrin as needed.
On examination of the cervical/thoracic/lumbar spine, there is mild tenderness to palpation over the paraspinal

It was noted that since the last evaluation, the IW notes subjective worsening of his neck, middle-back and low back pain and he demonstrates a 15 degree deterioration in cervical flexion, 10 degree deterioration in cervical extension, 10 degree deterioration in cervical rotation bilaterally, 15 degree deterioration in lumbar flexion, and 5 degree deterioration in lumbar extension.
With resumption of a regular physical therapy program, short term goals include subjective decrease in his neck pain, middle-back pain, and low back pain as well as objective improvement in cervical and lumbar range of motion of 5-10 degrees, as well as improvement in his ability to perform his functional activities. Long term goals include a return to his prior level of function as well as safely perform all activities of daily living.
Assessments include multiple cervical spine disc bulges and disc herniations, multiple lumbar spine disc bulges and disc herniation and thoracic spine