DOI: 2/15/2013. Patient is a 37-year-old male route sales representative who sustained a work-related injury while he was on a ladder putting clothes in his locker and a 50-pound bench fell and hit his head. Per OMNI, he was diagnosed with cervical strain, concussion with loss of consciousness and contusion of head.
The patient underwent anterior cervical discectomy and fusion with placement of intervertebral cage at C4-5, C5-6 and C6-7 and anterior instrumentation at C4-5 and C6-7 on 9/9/2015.
Per AME on 02/11/16 by Dr. Wakim, it was opined that the IW is not at maximum medical improvement (MMI). He will reach MMI on 09/2016. He has had a total of 11 PT sessions. Patient is currently taking Norco and Restoril. He has been dispensed with an H-wave unit for home with and reports benefit. …show more content…
Per medical report dated 05/16/16, patient continues to utilize Norco and Restoril, with good benefit for his ongoing symptoms.

Based on the progress report dated 07/11/16 by Dr. Bergey, the patient continues to have neck pain and stiffness with limited range of motion that radiates to the top of the left shoulder.
He rates his pain at 4/10 with medications and 5-7/ 10 without medications.
The patient has complaints of lower back pain, unchanged from last visit, rated 6/10 with medication, which increases to a 7/10 without