Occupational Trauma Case Study

DOI: 6/22/2015. Patient is a 44-year old male driver who sustained injury to his neck, back, right shoulder and psych when a car ran into his truck at stoplight. Per IME dated 10/16/15 by Dr. Patrick Hughes, the patient should see his physician once a month for 3 months and should then be re-evaluated. An end result has been achieved. For his cervical strain, a moderate 50% partial disability was given. He has not reached maximum medical improvement for his cervical strain. Attached is the psychiatric IME dated 11/10/15.

Per PT note dated 10/28/15, the patient has completed 32 sessions of PT. He has a diagnosis of cervical strain and right shoulder strain. Treatment has included moist heat, electric stimulation, ultrasound and a variety of exercises. The patent has made minimal gains in therapy. He continues to report dizziness, headaches and occasional increase in pain about his neck region. Although, these complaints have remained unchanged, it is believed that therapy would be of benefit.
It was noted that occupational therapy will start this week. He will start PT again to help him progress toward improvement
On examination of the neck, there is pain on right turning to the left. He is tender to light touch on the right posterior neck and occiput. There is limited flexion and turning to the left. There is tenderness form the trapezius, neck and middle back