The patient is a 45-year-old female who was the restrained driver of a vehicle involved in a motor vehicle accident on April 9. 2013. The patient reports that she was stopped and “rear-ended” by another vehicle at that time. Since that time, she reports neck pain and low back pain. She does report numbness and tingling in the left upper extremity at times. She denies any other pain, weakness, or numbness shooting to her arms or legs. She has been receiving physical therapy and chiropractic treatments with positive results although she does continue to have pain. She reports that she has been prescribed medications and takes these on an as needed basis. She has had MRIs done of cervical and lumbar spine. MRI of the lumbar spine revealed a herniated disc at L3-L4 as well as right lateral stenosis of the right L5 nerve root. I am awaiting the Radiology report of the cervical spine.
1. Posttraumatic cervical sprain/strain.
2. Cervical radiculopathy.
3. Posttraumatic lumbar sprain/strain.
4. Lumbar herniated disc.
The patient and I did have a nice talk today regarding her pain and overall plan of care. She has been having positive results with physical therapy and chiropractic treatments and I therefore recommended that she continues to see a chiropractic physician as well as physical therapist. I am recommending that she continue three times a week for next four to six weeks at which time she will be reevaluated. She will use ice 20 minutes at least twice daily. We did discuss gentle home exercise. I await the results of her cervical MRI scan. She does have radicular symptoms and I do feel that she would benefit from electrodiagnostic testing. I do feel that the patient would benefit from trigger point injections. She does have significant trigger point injections to multiple areas and she is amenable to having this procedure performed as she does have significant pain which has persisted despite therapy and home exercise. We will ask the insurance company for permission before beginning these treatments. The patient will call me if there are any questions or concerns prior to her next visit.