The patient is here for an initial evaluation for pain in the neck with radicular symptoms down the left arm and pain is in the left shoulder. Pain is in the low back. The patient was a restrained driver of the car, was hit from behind on November 16, 2011. After the accident, the patient has felt pain and started seeing her chiropractic and doing chiropractic therapy since then, which seems to help and helped her a little bit. She is still in significant amount of pain and more severe pain in the neck and left arm as 7/10 and pain in the back is about 4/10. The pain in the neck goes down the left arm and she feels tingling in the hand and the fingers. The pain in the back is predominantly axial, rarely goes down her the leg. Also find it difficult to lift anything with the left shoulder. She works as school bus driver and sometimes it is difficult for her to turn her neck towards the left side or use her left arm very quickly. She is right-handed. As per patient, she is taking Advil or aspirin on as needed basis to help in pain. Sometimes the pain is so bad she finds it difficult to sleep at nighttime and describes the pain as achy, burning, numbness, sharp, stabbing, and tingly.
Left shoulder supraspinatus tendonitis versus partial rotator cuff tear.
Lumbar facet syndrome.
Myofascial pain syndrome.
1. The patient is still in lot pain in the neck and left shoulder. I will request authorization from the patient’s insurance for a MRI of the C-spine and a MRI of the left shoulder without contrast.
2. In the interim, the patient will continue with chiropractic therapy. I also prescribed the patient naproxen 500 mg p.o. b.i.d. with food. I will decide her further course of treatment depending on the result of the above test.