21/05/2011 - Weebly



MEDICO-LEGAL REPORTPrepared ByDomenico Zingaro, RMTRegistered Massage TherapistCLIENT:DATE OF BIRTH:ADDRESS:OCCUPATION:DATE OF ACCIDENT:LOCATION OF CLINIC:DATE AND TIME OF APPOINTMENT:DATE OF REPORT:PREPARED FOR:Carly Westbrooke19/03/87127 Aberdeen Blvd.Burlington, ONN0D 8V3Waitress08/02/11DZ Massage Therapy Clinic27 Clayton Ave.Hamilton, ONL9G 4X320/05/2011 10:00am21/05/2011Allstate InsuranceA. IntroductionReferences used within this document are the client’s health history and SOAP notes. I, Domenico Zingaro, am the treating practitioner of client, Carly Westbrooke.B. Analysis of InformationMy client, Ms. Westbrooke, is a 26-year-old female who works as a waitress at Milestones Restaurant. She has never been to a massage therapy clinic prior to the appointment and was referred by her doctor. Ms. Westbrooke has been complaining of headaches that form around the side of her head (temporal region) that tend to transform into migraines. Prior to her accident, Ms. Westbrooke has never had headaches/migraines as bad as she describes. When she receives a headache, they hinder her eye sensitivity to light, hearing of any noises and make her weak and nauseous. Ms. Westbrooke is in good health condition and not taking any medication other than Advil for her headaches/migraines.After Ms. Westbrooke’s health history, I completed a number of assessments, the first being a pain assessment. She had advised me that she had recently been in a car accident where she had been hit from behind very aggressively while driving to work. She informed me that her accident occurred on 8 February 2011 in the afternoon. When Ms. Westbrooke receives a headache, she rates it as a 5/10 (0 being no pain and 10 being extreme pain) but at times it may escalate to 8/10, which are then migraines. She takes Advil and sleeps to make her headache/migraine go away. Bright lights, loud noises, and strong scents worsen her headaches/migraines. When receiving a headache/migraine, Ms. Westbrooke finds that she is unable to function properly through her activities of daily living. She is unable to drive, speak on the phone, read a book, go on her computer and listen to the radio. I had in mind that the complaint of receiving intense headaches at the side of her head is a possible trigger point in her upper back muscle. Postural assessment was unremarkable, along with her active range of motion for her neck (cervical region). Some pain had been persistent when performing passive range of motion, when applying overpressure when bending her neck to look down (flexion of neck). With resisted range of motion, her strength seemed to be good (either Grade 4/5 or Grade 5/5). Some manual muscle tests I performed on Ms. Westbrooke were for her upper back muscle (Trapezius), and neck muscle (Sternocleidomastoid). I then performed some special orthopedic tests revolving around the neck (cervical region). Once all the assessments were completed, I palpated the area and felt that Ms. Westbrooke’s upper neck muscle was tight (Trapezius). My clinical suspicion was that there was a trigger point in Ms. Westbrooke’s upper neck muscle, which is causing her headaches at the side of her head (Temporal region). I proposed a treatment of a 30-minute massage treating her head, neck, shoulder and upper back region. What I had found when massaging Ms. Westbrooke, were two trigger points in her neck area and had released them. Ever since then, Ms. Westbrooke hadn’t complained of headaches around the side of her head as often. I feel that Ms. Westbrooke had received the trigger points in her neck from her car accident 3 months prior to her appointment. The aggressive collision from behind would have strained her neck muscles, causing trigger points to form. If any questions are unanswered, please feel free to contact me at my office, information located above. My phone number is (905)664-9023. SignatureDate___________________________________________________________________________ ................
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