The patient is a 75-year-old male who was the retrained driver of a vehicle involved in a motor vehicle accident on May 25, 2013, who presents today for further evaluation and treatment of injuries. Specifically, he reports pain to his neck as well as his low back, right knee, and right hip. He denies pain, weakness, or numbness, or tingling to his arm or legs with the exception of some numbness and tingling to both upper extremities, which occurs primarily at night. He also reports that he does lose strengthen in his arms at times, which causes him to drop things. He has had an MRI scan of his lumbar spine as well as his right hip and cervical spine. An MRI of the cervical spine revealed multiple herniated discs especially at C3-C4, C4-C5, C5-C6, and C6-C7 with spinal cord and nerve root impingement were noted. An MRI of the lumbar spine also revealed multiple herniated disc. Specifically, areas of disc herniations were noted at L1-L2, L2-L3, L3-L4, and L4-L5. MRI of the right hip revealed mild degenerative changes of the right hip. It also noted abnormal prostate, but the patient and I discussed this issue and he is aware of this and is under the care of another physician for this issue. The patient has been receiving physical therapy and sees a chiropractic physician. He reports positive results from these treatments, but is frustrated as his pain can continues. He reports the neck pain is the worst at this time. The patient also reports occasional headaches since this accident occurs. The patient denies any significant history or similar symptoms to the above mentioned areas of the pain with the exception of some lower back pain and right knee pain. However, he reports that his low back pain had completely resolved and that he was pain-free for about two years prior to this new injury. While he has had some right knee pain, he reports that this accident significantly exacerbated minor pain that he had in the past.
1. Posttraumatic cervical sprain/strain.
2. Multiple cervical herniated discs with possible radiculopathy.
3. Posttraumatic lumbar sprain/strain.
4. Multiple lumbar herniated discs.
5. Right hip sprain.
6. Exacerbation of chronic right knee pain.
The patient and I did have a nice talk today regarding his pain and overall plan of care. He has also persistent pain to multiple areas despite aggressive therapy. Therefore, I am recommending some injection procedures. The patient and I discussed trigger point injection. He does have multiple areas of significant trigger points and I do feel that he would benefit from this. We will ask his insurance company before proceeding.
In addition, I do feel that the patient would benefit from electrodiagnostic testing. He does have multiple herniated discs to his cervical and lumbar spine. He has radicular symptoms to both upper extremities and does have significant right hip pain, which is not explained by his MRI scan of the right hip. Electrodiagnostic testing may help us to further determine the etiology of his symptoms.
The patient will continue with therapy and continue to follow up with this chiropractic physician, as well as any other physicians he has seen. He will call me with any questions or concerns prior to our next visit.