The patient presents today for a follow-up visit. She was last seen here on May 8, 2013 . He had sent her for MRI of her left shoulder and MRI of her lumbar spine. She continues to have severe mid-to-low back pain in addition to progressively worsening left shoulder pain.
In summary, she was involved in a motor vehicle accident on April 1, 2013 when she was driving and hit a car in front of her at approximately 15 miles per hour while in Sayreville. She suffered low back pain, left shoulder pain, left knee pain and right ankle pain. On April 29, 2013, she was again hit from behind when she slid on slick road surface. That day, there did not seem to be an issue but the next day, she had a worsening of her shoulder and back pain for approximately three days before the worsening pain returned to normal levels back to the April 1, 2013 accident.
Today, she continues to have significant pain in the posterior aspect of the left shoulder, anterior aspect of the left shoulder, and pain up into the neck. She states that after the physical therapy workout yesterday, she developed a severely stiff neck. She is unable to rotate to the right at all today. Continued pain in the mid to low back as well.
Current medications include ibuprofen.
1. Status post motor vehicle accident on April 1, 2013.
2. Status post motor vehicle accident of April 29, 2013.
3. Status post MRI of the lumbar spine on May 20, 2013.
4. Status post left shoulder MRI May 20, 2013 at Raritan Bay Medical Imaging.
5. Severe and debilitating left shoulder pain; the patient is very guarded today on examination.
6. Mid and lower back pain; likely somatic dysfunction with facet syndrome and sacroilitis.
I had a lengthy visit with Cassie today. We will set her up for CT arthrogram of the left shoulder as soon as possible and I am going to place her in a immobilization splint, which she can purchase on her own at the pharmacy. I did provide her with a prescription. I want her to hold on any physical therapy involving the left shoulder until we have obtained the CT arthrogram due to aforementioned imaging study findings and her significant guarding today.
She may continue with her physical therapy for her low back strain. I will start her on Medrol Dosepak as well as give her Vicodin and Valium today. She is having problems sleeping and getting comfortable. Hopefully, the Valium will help with spasm and the vicodin will help with the bony pain especially with concern over the issue with the glenoid and extensive labral tearing. We will see how well she does over the next few weeks. I would like her to see one of the providers here for follow-up after her CT arthrogram to discuss the result as that she may well need a referral to an orthopedic surgeon.
She is in agreement with this plan and will call with any questions or concerns.