Posttraumatic cervical sprain/strain

The patient is a 55-year-old female who was a restrained passenger of a vehicle involved in a motor vehicle accident on June 10, 2013. She presents today for further evaluation and treatment of her acute injuries. Specifically, she reports neck pain, low back pain, chest pain, and left knee pain. She does report radiation of pain from the neck to both upper extremities and does have numbness and weakness to the right upper extremity. She reports radiation of pain from her low back to the right lower extremity, as well as weakness to her right lower extremity. She denies any numbness or tingling. She reports that her chest pain was caused from seatbelt and airbag deploying and reports that her left knee hit the dashboard and is bruised. The patient was taken to the emergency department by EMS from the scene of the accident. She reports that significant workup was done including x-rays and she believes CT scans. She reports that she was told there were no fractures. She was prescribed Percocet as well as soft cervical collar and referred to a neurologist. She did seek the neurologist to order an MRI scans of her neck, low back, and knee. She would refer her to this office for further treatment. The patient does have a history of neck and low back pain from a prior injury. She reports that these symptoms completely resolved greater than five years ago.

1. Posttraumatic cervical sprain/strain.
2. Cervical radiculopathy.
3. Posttraumatic thoracic sprain/strain.
4. Posttraumatic lumbar sprain/strain.
5. Lumbar radiculopathy.
6. Sternal contusion.
7. Left knee contusion.

The patient and I did have nice talk today regarding her pain and overall plan of care. She will continue to follow up with her neurologist and has had MRI scans ordered. She will copy send to this office and I await these results. In the meantime, I will get the patient involved with physical therapy. Physical therapy will initially consist of therapeutic modalities and then progress to increasing range of motion and eventually to strengthening. The patient will use ice 20 minutes at least twice daily at home and we did discuss gentle home exercise. I do think the patient would be an excellent candidate for trigger point injections. We will request for the approval from her insurance to perform these injections. She will continue with her current medications. She will call me with any questions or concerns prior to her next visit.


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