myoActivation Consultation [Heidi]

myoActivation Consultation Date: 2024 11 01 Dear Dr. Smith, "Thank you for your referral of this pleasant" 35 year old female. "This consultation note reflects my first encounter with your patient." HISTORY Pain Issue 1 Patient reports a sharp pain in the lower back, rated 6/10. The pain started two weeks ago after lifting a heavy box. It is aggravated by prolonged sitting and bending. Alleviating factors include rest and heat. Associated symptoms include stiffness. The pain limits her ability to sit for more than 30 minutes. Pain Issue 2 Patient reports a dull ache in the right shoulder, rated 3/10. The pain started gradually over the past month. It is aggravated by overhead activities. Alleviating factors include rest and ice. There are no associated symptoms. The pain does not significantly impact her daily activities. Functional impairment, most difficult movement Difficulty reaching overhead and bending over. Occupations Over Lifetime: Patient has worked as a teacher for 10 years. Handedness Right-handed. Past Medical History Patient has a history of seasonal allergies. Current Medications Prescribed * Loratadine 10mg daily. Allergies * Penicillin (rash). ASSESSMENT Plantar Weight (Patient reports more weight on the right foot). Postural Symmetry (Slight forward head posture and rounded shoulders observed). TREATMENT "All myoActivation treatment involves injections of 0.9% normal saline microaliquots precisely targeted to densities within myofascial tissue at palpable painful points." BASE Test Series 1 Extension Arms Raised Patient reports pain in the lower back, rated 7/10. Limited range of motion. Pain decreased after treatment. Extension Arms Down Patient reports no pain. Flexion Arms Down Patient reports no pain. Squat Arms Down Patient reports no pain. Squat Arms Raised Patient reports pain in the right shoulder, rated 4/10. Limited range of motion. Pain decreased after treatment. Lateral Arch to Patient's Right Patient reports no pain. Lateral Arch to Patient's Left Patient reports no pain. Procedural Treatment 1 * Right Trapezius, 27 gauge, 1 inch. * Left Erector Spinae, 27 gauge, 1 inch. BASE Test Series 2 Extension Arms Raised - Pain in lower back reduced to 3/10. Extension Arms Down - No pain. Flexion Arms Down - No pain. Squat Arms Down - No pain. Squat Arms Raised - Pain in right shoulder reduced to 2/10. Lateral Arch to Patient's Right - No pain. Lateral Arch to Patient's Left - No pain. Procedural Treatment 2 * Right Rhomboids, 27 gauge, 1 inch. * Left Quadratus Lumborum, 27 gauge, 1 inch. BASE Test Series 3 Extension Arms Raised - Pain in lower back reduced to 1/10. Extension Arms Down - No pain. Flexion Arms Down - No pain. Squat Arms Down - No pain. Squat Arms Raised - No pain. Lateral Arch to Patient's Right - No pain. Lateral Arch to Patient's Left - No pain. Procedural Treatment 3 * Right Levator Scapulae, 27 gauge, 1 inch. * Left Multifidus, 27 gauge, 1 inch. BASE Test Series 4 Extension Arms Raised - No pain. Extension Arms Down - No pain. Flexion Arms Down - No pain. Squat Arms Down - No pain. Squat Arms Raised - No pain. Lateral Arch to Patient's Right - No pain. Lateral Arch to Patient's Left - No pain. Procedural Treatment 4 * Right Teres Minor, 27 gauge, 1 inch. * Left Psoas, 27 gauge, 1 inch. BASE Test Series 5 Extension Arms Raised - No pain. Extension Arms Down - No pain. Flexion Arms Down - No pain. Squat Arms Down - No pain. Squat Arms Raised - No pain. Lateral Arch to Patient's Right - No pain. Lateral Arch to Patient's Left - No pain. Procedural Treatment 5 * Right Supraspinatus, 27 gauge, 1 inch. * Left Iliacus, 27 gauge, 1 inch. BASE Test Series 6 Extension Arms Raised - No pain. Extension Arms Down - No pain. Flexion Arms Down - No pain. Squat Arms Down - No pain. Squat Arms Raised - No pain. Lateral Arch to Patient's Right - No pain. Lateral Arch to Patient's Left - No pain. Procedural Treatment 6 * Right Infraspinatus, 27 gauge, 1 inch. * Left Piriformis, 27 gauge, 1 inch. BASE Test Series 7 Extension Arms Raised - No pain. Extension Arms Down - No pain. Flexion Arms Down - No pain. Squat Arms Down - No pain. Squat Arms Raised - No pain. Lateral Arch to Patient's Right - No pain. Lateral Arch to Patient's Left - No pain. Procedural Treatment 7 * Right Subscapularis, 27 gauge, 1 inch. * Left Gluteus Medius, 27 gauge, 1 inch. BASE Test Series 8 Extension Arms Raised - No pain. Extension Arms Down - No pain. Flexion Arms Down - No pain. Squat Arms Down - No pain. Squat Arms Raised - No pain. Lateral Arch to Patient's Right - No pain. Lateral Arch to Patient's Left - No pain. Procedural Treatment 8 * Right Teres Major, 27 gauge, 1 inch. * Left Gluteus Maximus, 27 gauge, 1 inch. AFTERCARE Patient "was advised not to undertake exertional activities for the next 5 days. Helpful to change posture every 15-20 minutes. Important not to walk more than 15 minutes at any one time but can engage in short walks multiple times per day." Follow-up in 2 weeks.