The patient is a 54-year-old male who was an unrestrained passenger of a vehicle involved in a motor vehicle accident on March 17, 2013. He presents today for further evaluation and treatment of his acute injuries. Specifically, he reports pain to his neck and low back region. He reports radiation of pain to both his upper extremities as well as numbness at times to both upper extremities. He reports low back pain with radiation to the left lower extremity, which is described primarily as a tightening and cramping type sensation. He reports that he was transported to the emergency department by the EMS from the scene of the accident. He reports that x-rays were performed which did not reveal any fractures. He was prescribed Lortab. He was seen one week later by another physician who gave two injections to his buttock region and prescribed Percocet and Flexeril. He went on to see a different physician, who is an orthopedic surgeon. He reports that he was prescribed Percocet and Xanax by this orthopedic surgeon and is almost out of these medications at this time. The patient where he is visiting family. He has been getting physical therapy done three times a week. He reports that MRI scans have been ordered of his neck and back.
1. Posttraumatic cervical sprain/strain with possible cervical radiculopathy.
2. Posttraumatic lumbar sprain/strain with possible radiculopathy.
The patient and I did have a discussion today regarding his overall symptoms. I do feel that the patient will benefit from trigger point injections. He does have multiple areas of pain with trigger points and we will attempt to get authorization from his insurance company to perform these injections. I am hopeful at all that he will be able to obtain some relief from these injections and it will help with his overall progression toward overall improvement. The patient will continue with physical therapy that he has been receiving. He will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. I am referring him to see a pain specialist Dr. for medication. The patient will call me with any questions or concerns prior to our next visit.