The patient comes in today for a follow-up visit. She continues to have neck pain and headaches from a motor vehicle accident on February 22, 2012. She has started physical therapy and seems to have some improvement in her symptoms. She still has a lot of anxiety from the accident. She denies any changes in characteristic or nature of her pain. She is using over-the-counter analgesic as needed for pain. She denies any radiating pain or numbness or tingling down the extremities. She denies any bowel or bladder dysfunction. She denies any changes in her past medical history, past surgical history, allergies, medication history, family history, social history, or review of systems.
Continue physical therapy three times per week and we will recommend acupuncture as well for her symptoms. She will continue to use over-the-counter anti-inflammatory as needed for pain and inflammation. We will see her back in four-week period of time. If improvement is not seen with conservative measures, we will recommend an MRI.