Bilateral upper trapezius sprain/strain

The patient is a 51-year-old female who was the restrained driver of a vehicle involved in a motor vehicle accident on May 16, 2013. She presents today for further evaluation and treatment of her injuries. Specifically, she reports pain in right neck and upper back and across both shoulders. She denies significant pain, weakness, or numbness shooting to her arms or legs. She has been receiving physical therapy and chiropractic treatments with positive results although is frustrated as she continues to have pain. She reports that she has been prescribed medications although prefers not to be on medications due to GI side effects. She has had x-rays performed, which did not reveal any fractures. She was sent for MRI scans, but is extremely claustrophobic and therefore has not been able to get the tests performed as of yet.

1. Posttraumatic cervical sprain/strain.
2. Posttraumatic thoracic sprain/strain.
3. Bilateral upper trapezius sprain/strain.
4. Left shoulder sprain.

The patient and I did have a nice talk today regarding her pain and overall plan of care. She has done well with physical therapy and seen her chiropractic physician; however, she is frustrated that she continues to have significant pain and does wish to have other treatments done to try to improve her symptoms. She feels that her pain is severe. We did discuss trigger point injections. She is a very needle phobic, but has agreed to try this procedure as she wishes to do something to improve her symptoms. Therefore, we will request pre-approval from her insurance carrier and then proceed if we do get approval.

The patient will continue with physical therapy and continue to follow up with her chiropractic physician. She will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. She does have prescription for MRI scans and is looking for course with an open unit. She has tried once per reports that she was too claustrophobic and she is trying to get the courage to try again. She is looking for a facility, which is more suitable for her. Once she has this done, I will review the results with her. She will call me with any questions or concerns prior to our next visit.


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