The patient is a 55-year-old female who was involved in a motor vehicle accident on August 28, 2012. She was the driver of her vehicle that was at a stop light when she was rear-ended by another car. The car suffers severe damage. She drove herself to the hospital where she was treated and released. Immediately after the accident, she started experiencing pins and needle, sharp stabbing pain in the right neck that radiated into her face, head, shoulder and shoulder blade on the right side. She did not lose consciousness during the accident. She has been controlling her pain with over-the-counter medications such as Motrin. Her pain has been worsening to the point that it is interfering with her enjoyment of life and activities of daily living. She was involved in a motor vehicle accident three years ago with no sequelae. She does have a diagnosis of rheumatoid arthritis and she was experiencing some diffuse achiness in the neck and shoulders. The pain that she is experiencing now is different and a lot worse than the pain that she was having before the accident. She describes her pain as follows: Triggering event: Motor vehicle accident on August 28, 2012. Duration: Constant. Quality and intensity: 8/10 to 9/10. Radiation distribution: Right neck radiates to the right shoulder and down to the medial margin of the right shoulder blade. At this point, the pain is not radiating to the extremity. Aggravating factors: Moving the neck and also raising the arms. Alleviating factors: Motrin, hot and cold packs. Associated factors: Tingling, numbness, and aching sensation.
2. Whiplash injury.
3. Cervical musculoskeletal sprain/strain.
4. Facet joint derangement.
5. Morbid obesity.
6. Sleep apnea.
1. I have discussed with the patient that treatment plan will start with the conservative management. I will start her with chiropractic manipulations that will include massage therapy, ultrasound, and range of motion. She will be reevaluated in four weeks. At that time, we will determine the progress and improvement. A consideration will be the performance of cervical and medial nerve blocks if she is not improving appropriately. Also, the consideration for her will be to go to physical therapy program. A prescription for tramadol 50 mg one tablet p.o. q.8h., 60 tablets with no refill was given to the patient to use at nighttime in order to decrease her pain and allow her to rest. She will continue using the Motrin as needed.
2. These recommendations are based on the presenting symptoms today and they may change based on the patient’s progress in her symptomatology and physical findings. I am not ruling out any other interventional therapies as needed.
3. Follow-up will be in four weeks.