Patient Case Summary

DOI: 5/14/2015. Patient is a 48- year old male machine operator who sustained a cumulative injury from 12/15/14 through 05/14/15 due t normal job duties.

Based on progress report dated 06/16/15, the patient reports that while performing her usual and customary work duties, she developed psychological symptoms, insomnia and digestive system problems due to stress at work. Patient states her stress was caused by mistreatment by superiors and cell leads induding, but not limited to yelling, harassment, putting hands in the workers face in order for them to stop taking, threatening with warnings, move workers from stations just to bug them. She complains of anxiety, pain to digestive system and pain to neck and shoulders due to stress. She is currently taking an antibiotic due to an ear infection.

There is tenderness to palpation of the cervical paravertebral muscles. There is muscle spasm of the cervical paravertebral muscles.

Diagnoses are cervical myospasm, cervical sprain/strain, and depression/stress.

Treatment plan includes a trial of acupuncture 1 x per week for 6 weeks, trial of chiropractic treatment 1 x per week for 6 weeks, functional capacity evaluation (FCE) to further evaluate patient’s functional capacity and limitations, transcutaneous electrical nerve stimulation (TENS) unit in the form of interferential (IF)/Electrical Muscle Stimulation (EMS) unit and supplies, referral to psychologist in order to assist with patient’s stress, anxiety and depression, and X-ray studies of the cervical