The patient is a 64-year-old male who was the restrained driver of a vehicle involved in a motor vehicle accident on June 10, 2013. He presents today for further evaluation and treatment of his injuries. Specifically, he reports low back pain. He denies pain, weakness, or numbness shooting to his arms or legs. No additional complaints at this time. He has seen a chiropractic physician who has been receiving therapy. He denies seeing any other medical physicians prior to his visit with me today. He reports that an MRI again has been ordered and he is scheduled for electrodiagnostic testing this coming Thursday. The patient does have a history of low back pain; however, he reports that he was pain-free prior to this accident for at least one-year.
1. Lumbar sprain/strain.
2. Myofascial pain secondary to the above.
The patient and I did have a nice talk today regarding his pain and overall plan of care. We did discuss medications options. I would like for him to be on an anti-inflammatory medication. However, he reports allergy to all nonsteroidal anti-inflammatory medications. He reports that he developed severe stomach pain from these medications. Therefore, he will use ice 20 minutes at least twice daily for anti-inflammatory affects. I have prescribed cyclobenzaprine 10 mg one tablet before bed as needed to help reduce muscular spasm. We discussed that he will not drive or operate machinery while taking this medication. As he cannot take anti-inflammatory medications, trigger point injections may be useful to help reduce his inflammation as well. We will ask his insurance carrier for pre-certification before initiating trigger point injections. I did discuss risks and benefits with the patient and he does wish to proceed with this treatment if possible. The patient will continue to follow up with his chiropractic physician and continue with therapy. He reports to me that an MRI scan of his lumbar spine has been ordered and he is ordering electrodiagnostic testing to be performed this coming Thursday. I await these results. He will call me with any questions or concerns prior to our next visit.