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Clinical Notes & Documentation
DAILY NOTES - Susan Martin (ID# 563971821) - February 10, 2004
Examined by: David L. Johnson, D.C.
( SUBJECTIVE ) At today's visit, the following symptoms were identified by Mrs. Martin:
- Headache pain affecting the entire head. The headache is moderate to severe in intensity. The symptoms appear on a frequent basis. Susan indicated that the headaches have been temporarily reduced since the last treatment.
- Bilateral neck pain and stiffness. The neck discomfort is moderate. Susan experiences the symptoms with movement. The pain is represented as a throbbing sensation. According to Susan, her symptoms have been reduced since the last treatment.
Mrs. Martin approximated her overall primary pain to be a 6 on a scale from 1 to 10, with 1 being no pain and 10 being the most severe. During her last visit, Susan rated her primary pain as a 7.
( OBJECTIVE ) A muscle spasm of mild intensity was revealed in the bilateral lower cervical regions. The left upper cervical region was in a state of moderate muscle spasm. The paraspinal musculature was notably tender during examination of the bilateral lower cervical regions. A mild decrease of the cervical flexion was observed. A moderately decreased cervical range of motion was observed during the right lateral flexion and left lateral flexion. During the cervical right lateral flexion and left lateral flexion, Susan indicated she felt pain.
( ASSESSMENT ) It is recommended that Susan return to her work activities with restrictions. Susan's condition is improving.
( PLAN ) Susan will continue on her current plan. She will continue to be seen 2 times per week for a period of 4 weeks. Susan has been instructed to rest at home.
( TREATMENT ) Today's treatment consisted of the following:
A specific adjustment was provided to the C1, left C2, and right C5 to correct malalignments and restore normal mobility. Electrical myostimulation therapy was applied to the bilateral upper cervical and bilateral lower cervical regions. Acupuncture therapy was applied to the right upper cervical and right lower cervical areas.
Limitations and restrictions have been discussed with Mrs. Martin, as well as proper biomechanics.
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