Posttraumatic thoracic sprain/strain

The patient returns today for reevaluation. She reports no change since her last visit. She reports continued neck pain, upper back pain, low back pain, sternal pain (although this is improving) as well as left knee and right shoulder pain. She has been told that she is a good candidate for surgery of her left knee, but there are some financial issues, which may be precluding her from having the surgery. She denies any new complaints at this time.

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.
8. Right shoulder sprain.

The patient and I had another nice talk today. Prior injections were helpful and she therefore decided to proceed with addition of trigger point injections. She did have significant trigger points to the right cervical paraspinal musculature, right upper trapezius, and right scapulothoracic region. A solution of lidocaine 1% was used. Injections were done to all the above-mentioned trigger point regions. The patient tolerated the procedure well. There were no complications. I am referring the patient to see my partner Dr. to discuss interventional procedures. She will call me with any questions prior to her next visit. She will continue seeing her other physicians and continue with her current therapies in the meantime.


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