The patient is a 43-year-old female who was a restrained driver of a vehicle involved in a motor vehicle accident on January 8, 2013. She is here today for further evaluation and treatment of her acute injuries. There is a language barrier and no one is to interpret today, but I was able to gather most of the pertinent information from her. Specifically, she reports pain to her neck, mid back, and low back. She also reports radiation of pain to the right shoulder region in addition to headaches. She denies any loss of consciousness. She reports that she was evaluated at Hospital following this injury. She also has a significant workup done including MRI scan of the cervical spine and electrodiagnostic testing. MRI of the cervical spine revealed herniated discs at C4-C5, C5-C6 and C6-C7. Electrodiagnostic testing revealed a bilateral C5, C6 and C7 radiculopathies.
1. Multiple cervical herniated discs.
2. Cervical radiculopathy.
3. Persistent posttraumatic cervicalgia.
4. Persistent posttraumatic thoracic pain.
5. Persistent posttraumatic lumbago.
6. Posttraumatic cephalalgia.
7. Right shoulder sprain.
The patient and I did have nice talk today regarding her pain and overall plan of care. She will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. She will continue with physical therapy and continue to see her chiropractic physician and I have written prescriptions for her to continue to do both of these. I have discussed possible additional treatment options with her. She does have significant trigger points as well as shoulder pain. As she has trigger points to the cervical, thoracic and lumbar paraspinal musculature as well as the right upper trapezius, I am hopeful that trigger point injections will help with her neck pain, back pain, and right shoulder pain. We will ask for pre-certification from her insurance carrier before proceeding. If trigger point injections are ineffective, I will refer her to my partner Dr. to discuss interventional procedures such as surgical epidural steroid injections. She does have pain radiating into her right shoulder as well as MRI scan showing herniated discs and electrodiagnostic testing, which shows cervical radiculopathies at several levels. I will have the patient to follow up with me in two weeks’ time. She will call me with any questions or concerns prior to this.