HISTORY OF PRESENT ILLNESS:
The patient returns today for reevaluation. She reports continued severe pain to multiple areas including her neck, upper back, low back, chest and bilateral knees. She reports continued radiation of pain to right upper extremity as well as the right lower extremity. She denies any specific new complaints. She has been attending therapy. She reports that this has provided at least some minimal relief to her symptoms but she does continue to have significant pain.
General: Alert and oriented. HEENT: Normocephalic. Chest: Normal respiratory effort with good chest wall excursion. Abdomen: Soft and nontender. Extremities: No clubbing, cyanosis, or edema. Neuromuscular examination: Range of motion is significantly reduced to the cervical and thoracolumbar spine. Spasm and rigidity is noted to bilateral cervical, thoracic, and lumbar paraspinal musculature. Trigger points are noted to all these regions as well as bilateral upper trapezius muscles and bilateral upper gluteal musculature. There is pain to palpation at the mid sternal region. There is pain to palpation of bilateral knees.
- Posttraumatic cervical sprain/strain.
- Cervical radiculopathy.
- Posttraumatic thoracic sprain/strain.
- Posttraumatic lumbar sprain/strain.
- Lumbar radiculopathy.
- Sternal contusion.
- Left knee contusion/pain.
- Right knee sprain.
The patient and I did have another nice talk today. She does continue to be in significant pain. She was seeing who did prescribe pain medications and she will make another appointment so that she can see him for continued Vicodin. She reports that this was prescribed by him previously. If she is unable to continue to see for any reason. In the meantime, she will continue with therapy as well as ice and home exercise. We have requested prior authorization from her insurance company for trigger point injections and are awaiting her response. She would like to have injections done and if we get authorization, we will proceed with this. The patient also had MRI scans. MRI scan of the lumbar spine did reveal disc bulging at multiple levels most pronounced at L4-L5 and L5-S1. MRI of the cervical spine revealed a right paracentral disc protrusion at C6-C7 as well as disc bulging at C5-C6. I will have her follow up with me in two weeks’ time. She will call with me with any questions or concerns prior to this.