Neck pain, upper back pain, and low back pain.
HISTORY OF PRESENT ILLNESS:
The patient is a 24-year-old female who was a restrained driver of a vehicle involved in a motor vehicle accident on October 18, 2012. She presents today for further evaluation and treatment of her injuries. Specifically, she reports pain to her neck as well as well as low back. She reports numbness to both hands at times as well as weakness to both hands. She also reports low back pain with radiation to the right lower extremity as well as numbness to her right toes. She has substantial workup done including MRI scans and electrodiagnostic testing. MRI scans of her thoracic spine revealed exacerbation of the normal kyphosis. MRI of the cervical spine revealed bulging disc from C3-C4 through C5-C6. MRI of the lumbar spine revealed a disc bulge at L5-S1. Electrodiagnostic testing was done of upper and lower extremities. Upper extremity electrodiagnostic testing revealed bilateral cervical radiculopathies at C5, C6, and C7. MRI also revealed demyelinating neuropathy involving the left knee in sensory nerve. Electrodiagnostic testing of the lower extremities revealed lumbosacral radiculopathies on the right at L4, L5, and bilateral S1. The patient denies any prior history of similar symptoms. She reports occasional aches and pains in the past, but never needed any medical treatment.
PAST MEDICAL HISTORY:
The patient denies.
PAST SURGICAL HISTORY:
The patient denies.
No known drug allergies.
The patient reports positive tobacco and social alcohol use. She denies any illegal drug use. She works as a medical assistant.
REVIEW OF SYSTEMS:
As above only.
General: Alert and oriented. HEENT: Normocephalic. Chest: Normal respiratory effort with good chest wall excursion. Abdomen: Soft. There was some tenderness to the right upper quadrant (the patient is under workup in the past for gallbladder). Extremities: No clubbing, cyanosis, or edema. Neuromuscular examination: Sensation is intact in C5 to T1 dermatomes bilaterally, but decreased to light touch to the majority of the right lower extremity not following the dermatomal distribution. Deep tendon reflexes are equal and symmetrical to bilateral upper and lower extremities.
Motor is 5/5 bilaterally for shoulder abduction, elbow flexion, elbow extension, wrist extension, finger flexion, and finger abduction; 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, which is greater with cervical flexion and extension and with thoracolumbar flexion. Spasm and rigidity is noted to bilateral cervicothoracic and lumbar paraspinal musculature. Trigger points are noted into the right upper trapezius as well as the cervical paraspinal musculature, right scapulothoracic region, and right lumbar paraspinal musculature as well as right upper gluteal musculature.
- Persistent posttraumatic cervicalgia.
- Cervical radiculopathy.
- Persistent posttraumatic thoracic pain.
- Persistent posttraumatic lumbago.
- Lumbar radiculopathy.
The patient and I did have nice talk today regarding the pain and overall plan of care. We did discuss a number of treatment options including very conservative treatment, which would include only continue with physical therapy to more aggressive options such as referral for interventional procedures. We eventually decided to begin with something in between. The patient and I discussed the risks and benefits of trigger point injections and this patient would like to proceed with this option. We will ask her for authorization and if she is approved, we will proceed with this treatment. In addition, the patient will continue with therapy and continue seeing her chiropractic physician. She will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. I am prescribing two medications for him. She was taking naproxen in the past with positive results and I have prescribed naproxen 500 mg one pill twice daily for anti-inflammatory effects. We did discuss GI precautions. She was also prescribed cyclobenzaprine 5 mg one to two per hour q.h.s. p.r.n. We discussed that she will not drive or operate machinery while taking this medication. If trigger points and medications are unsuccessful, we will readjust the possibility of referral for interventional procedures. The patient will follow up with me in two weeks’ time. She will call me with any questions or concerns prior to this.