The patient is a very healthy 46-year-old male who was a restrained driver of a vehicle involved in a motor vehicle accident on December 20, 2012. He presents today for further evaluation and treatment of his injuries. Specifically, he reports neck pain with pain radiating into his left upper extremity. He also reports numbness and tingling as well as weakness to the left upper extremity. He has had an MRI scan which did reveal a left central disc herniation at C5-C6 probably in the left ventral portion of the cervical cord as well as bulging discs and foraminal stenosis in the cervical spine. It did take up an incidental finding of abnormal or mixed signal intensity within the right maxillary sinus, which was felt to be most likely due to chronic inflammatory disease. We have recommended that he had a CT scan of his sinuses for further evaluation. I did discuss this with the patient, who will take a copy of the MRI scan to his primary care physician for further evaluation. He is present during this dictation as well. The patient has had electrodiagnostic testing performed. Electromyography and nerve conduction services, which was performed on March 7, 2013 revealed a demyelinating neuropathy involving the right median sensory nerve as well as a cervical radiculopathy in the right at C5 and C6. The patient was seeing a pain management physician who was prescribing OxyContin. He is out of his medication now, but feels that he would need it. The patient denies any prior history of similar symptoms before this accident. He does report a prior accident in which he was treated for low back pain, but denies any history of neck pain.
1. Cervical herniated disc.
2. Cervical radiculopathy.
3. Posttraumatic cervical sprain/strain.
The patient and I did have a nice talk today regarding his pain and overall plan of care. He was frustrated as he continues to have significant pain and we did discuss treatment options. The patient agreed that he would like to try trigger point injections. He does have significant trigger points to his left upper trapezius, cervical paraspinal region, and left scapulothoracic region. I will request him approval from his insurance company before proceeding. If trigger point injection failed, he would be a candidate for cervical epidural steroid injections and I will refer him to my partner, Dr. X for further evaluation and possible treatment with cervical epidural steroid or other interventional procedures. In addition, the patient has been on OxyContin and I am referring him to Dr. for the possibility of continued OxyContin medication or whatever medications Dr. and the patient agree on.
The patient has been doing well with therapy. He will continue with physical therapy and continue to follow up with his chiropractic physician. He will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. The patient will call me with any questions or concerns prior to our next visit.