Cephalalgia

This is a 20-year-old female patient, who presents to the pain management center today as referral from Dr. complaining of neck, upper back pain, and headaches. The patient was involved in a motor vehicle accident on 06/02/2012. She was a restrained driver in a Chevrolet Cavalier. She was going east on Street when another vehicle was approaching on the oncoming lane and tried to make a left hand turn, cutting in front the patient and the patient impacted the car head-on. There was no loss of consciousness, but the airbag did deploy. She was transported to the emergency room after the accident in her boyfriend’s vehicle to Medical Center,. She was treated and released the same day. Since the accident, she has been undergoing chiropractic treatment three times per week since June 4, 2012. She has had no previous motor vehicle accidents and no previous injuries to the, head, neck, or back. She is having pain in the neck and upper back area more up to the left side with some pain in the lower back. She has shooting pains in the left forearm with numbness and tingling in the left hand. She is having daily headaches in the temples and the occipital region of the head since the motor vehicle accident. The headaches are dull in nature with associated nausea and trouble thinking straight. She rates the pain level as 8/10 on a visual analog scale and is aggravated with lifting and repetitive motion. The pain is decreased with rest, medications, and wrist brace. She has taken over-the-counter Tylenol which provides temporarily relief of her symptoms. Overall, she is seeing moderate improvement of chiropractic treatments over the last two months. The patient has dizziness associated with her headaches.

DIAGNOSES:
Cervical strain.
Cervical radiculopathy.
Cephalalgia.
Acute lumbar strain.
Benign positional vertigo.

RECOMMENDATIONS:
Clinical findings, assessment, diagnosis, prognosis, and treatment recommendations were discussed with the patient. She has had two months of conservative care without significant improvement in her symptoms of neck pain and headaches. We will recommend MRI of the cervical spine to rule out discogenic sources of her neck pain and radicular pain and we will recommend MRI of the brain because of the headaches and dizziness. We will recommend she continue with chiropractic treatments. I have ordered her Naprosyn 500 mg one q.12h. for pain and inflammation, #60 dispensed and Flexeril 10 mg half-to-one at night for muscle spasm. We will see her back after she has her MRI.

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