Neck pain, mid back pain, and low back pain.
HISTORY OF PRESENT ILLNESS:
The patient is a 33-year-old female who was a restrained driver of a vehicle involved in a motor vehicle accident on July 4, 2013. She presents today for further evaluation and treatment of her acute injuries. Specifically, she reports pain to her neck, mid back, and low back. She reports that her low back pain is the worst at this time. She does report radiation of pain to the right lower extremity, which she describes primarily as a tingling type sensation and also reports radiation of pain to the left upper extremity, which she also reports as a tingling sensation. She reports that her mid-back pain is only intermittent in nature. The patient specifically denies any prior history of similar symptoms before this accident. She has seen medical physician as well as chiropractic physician prior to her visit with me today. She has been receiving massage type therapies and chiropractic treatment as well as other therapy. She reports that she has been prescribed “pain medications” but does not remember the exact names of the medications. She continues to take these medications. She reports that x-rays were done on July 8, 2013, which did not reveal any fractures. She did have an MRI scan done of her low back, which was performed today. So, we did not have the results yet of this study.
PAST MEDICAL HISTORY:
The patient denies.
PAST SURGICAL HISTORY:
The patient denies.
No known drug allergies.
As above only.
The patient reports occasional social alcohol use and some tobacco use. She denies any illegal drug use. She is not currently working.
Remarkable for cardiovascular disease.
REVIEW OF SYSTEMS:
As above only.
General: Alert and oriented. HEENT: Normocephalic and atraumatic. Chest: Normal respiratory effort with good chest wall excursion. Abdomen: Soft and nontender. Extremities: No clubbing, cyanosis, or edema. Neuromuscular examination: Sensation is intact in C5 to T1 and L2 to S2 dermatomes bilaterally. Deep tendon reflexes are 2+ bilaterally in biceps, triceps, and brachioradialis, 2+ bilaterally in patella and Achilles. Motor is 5/5 bilaterally for shoulder abduction, elbow flexion, elbow extension, wrist extension, finger flexion, and finger abduction and 5/5 bilaterally for hip flexion, knee extension, ankle dorsiflexion, long toe extension, and ankle plantar flexion.
Range of motion is reduced to the cervical and thoracolumbar spine. There is pain with cervical flexion as well as thoracolumbar flexion. Spasms and rigidity is noted to bilateral cervical, thoracic, and lumbar paraspinal musculature. Trigger points are noted to the right greater than left upper trapezius muscles as well as to the lumbar paraspinal musculature.
- Posttraumatic cervical sprain/strain.
- Cervical radiculopathy.
- Posttraumatic thoracic sprain/strain.
- Posttraumatic lumbar sprain/strain.
- Lumbar radiculopathy.
The patient and I did have nice talk today regarding her pain and overall plan of care. She is receiving pain medications from her medical physician and will continue to follow up with him and follow his instructions. In addition, she has been receiving chiropractic treatments and therapy. I will write a new prescription for her to either start or continue with actual physical therapy. Specifically, we would like her to be getting physical therapy three times a week. Physical therapy will initially be giving her therapeutic modalities and progress to increase her range of motion and eventually strengthen her core musculature. The patient and I did discuss other treatment options such as trigger point injections. She is very needle phobic and we will consider this as a future option only if absolutely necessary. We will also discuss treatment options such as osteopathic manipulation therapy. She does not like the “correct.” However, I discussed that we can use methods such as muscle energy, which will allow her to have the benefits with the type of sensation that she does not wish to have. We will ask her insurance carrier for prior authorization. I also wrote the results of her MRI scan before making other decisions. She will call me with any questions prior to her next visit. I will have her follow up with me in two weeks’ time.