Form Pr-2 - Primary Treating Physician'S Progress Report (Pr-2) Sample

ADVERTISEMENT

Additional pages attached
State of California
Division of Workers’ Compensation
PRIMARY TREATING PHYSICIAN’S PROGRESS REPORT (PR-2)
Periodic Report (required 45 days after last report)
Change in treatment plan
Released from care
Change in work status
Need for referral or consultation
Response to request for information
Change in patient’s condition
Need for surgery or hospitalization
Request for authorization
Other:
Patient:
Last:
CARTER
First: LINDA
M.I.: J
Sex: FEMALE
DOB: 01/22/1972
Address: 100 WEST CALIFORNIA BOULEVARD
City: PASADENA
State: CA
ZIP: 91101
Occupation: BUS OPERATOR
SS #: ***-**-2222
Phone: (626) 555-0167
D.O.I.: 04/11/2012
Claims Administrator:
Name:
KAL-EL
Claim Number: 1000-11
Address: P.O. BOX 111
City: SANTA ROSA
State: CA
ZIP: 95401
Phone:
(707) 555-0167
Fax : (707) 555-0168
Employer Name:
DC UNIVERSE
Employer Phone: (626) 555-0101
Chief Complaints:
Neck and low back pain.
Subjective:
The patient complains of constant severe neck pain, which she rates at 8/10 on a pain scale, associated with numbness and tingling
sensation radiating to the upper extremities. She states that her pain is aggravated by moving her head from side to side, and is relieved
by taking ibuprofen. She also complains of constant severe low back pain which she rates at 8/10 on a pain scale, associated with
numbness and tingling sensation radiating to the lower extremities. She states that her pain is aggravated by lifting heavy objects or
bending, and is relieved by taking ibuprofen. The patient is having difficulty with ambulation. She is not attending any therapy at this
time.
Review of Systems:
Reviewed with patient. A total of 14 systems were reviewed with no change from my previous report dated December 5, 2014 except
as follows: Constitutional symptoms: The patient reports weakness and fatigue. Neurological: The patient reports numbness and
tingling sensation.
Past, Family, and/or Social History:
Reviewed with patient. No change from my previous report dated December 5, 2014.
Physical Examination:
Vital Signs: Blood pressure: 120/80 mmHg; Height: 5’4”; Weight: 237.4 lbs.; BMI: 40.7.
The patient is well-nourished, well-developed, and in no acute distress. The head is normocephalic and atraumatic. Facial bones are
intact without deformity or tenderness. Examination of the eyes reveals the pupils to be round and with consensual reaction to light and
accommodation. External auditory canals are nontender and noninflamed. The nose is atraumatic and without deformity. Normal
mucous membranes and without lesions. The neck is nontender and the trachea is located in midline. The chest is symmetrical and non-
tender. There is regular rate and rhythm. No murmurs, gallops, and rubs. The abdomen is soft and nontender with no organomegaly
or palpable masses. The patient has an antalgic gait. The patient is alert and oriented x3. Recent and remote memory intact. The
patient is pleasant and cooperative during the examination. Mood and affect are normal.
Examination of the cervical spine: The skin has no scar, ecchymosis, swelling, and laceration. There is mild torticollis to the left. The
left levator scapula has swelling/inflammation. There is tenderness over the C3-C5 spinous processes bilaterally and on the left trapezius
and paracervical muscles. There is restricted range of motion in all planes with flexion at 20 degrees, extension at 30 degrees, right and
left rotation at 40 degrees, and right and left lateral bending at 20 degrees. Cervical compression test and Spurling’s test are positive on
the left.
Examination of the lumbar spine: There is a well-healed surgical scar. There is slight flattening of the lumbar lordosis. There is
tenderness over the L3-S1 spinous processes and on the paralumbar muscles, bilaterally. There is restricted range of motion in all planes
with flexion at 40 degrees, extension at 20 degrees, and right and left lateral bending at 20 degrees.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 8