Neck pain and upper back

The patient is a 61-year-old male who was involved in a motorcycle versus motor vehicle accident on June 20, 2013. He was riding on a motorcycle which was hit from behind by a car. The patient is here for further evaluation and treatment of these acute injuries. Specifically, the patient reports that his pain is to his neck and upper back. He denies pain, weakness, or numbness shooting to his arms or legs. No additional complaints at this time. He reports that his pain was quite severe although has improved some with chiropractic therapy that he has been receiving. He now reports that his pain is 5/10 on a pain scale.

The patient was taken to the emergency department by EMS from the scene of the accident. He reports that x-rays as well as CT scans were done. These did not reveal any fractures. He reports that he was prescribed pain medications which he continues to take for his symptoms.

1. Posttraumatic cervical sprain/strain.
2. Posttraumatic thoracic sprain/strain.

The patient and I did have a nice talk today regarding his pain and overall plan of care. I am ordering an MRI scans of the cervical and thoracic spine. The patient will continue with chiropractic treatments and physical therapy. In addition, he will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. If his symptoms do not improve after more therapy, I have ordered an MRI scans of his cervical and thoracic spine. He has had significant trigger points, and therefore I will request from his insurance company authorization to perform trigger point injections. He agrees. He will continue with the medications he is currently taking. He will call me if there are any questions or concerns prior to our next visit.


Leave a Reply