The patient is a 38-year-old male who was the restrained driver of a vehicle involved in a motor vehicle accident on December 17, 2012. He presents today for further evaluation and treatment of his injuries. Specifically, he reports pain in his neck and low back. He does report positive radiation of pain to both upper extremities as well as tingling to both upper extremities. He reports weakness to both hands. He reports low back pain and does report weakness as well as pain to both lower extremities, especially when trying to do exercises. The patient reports that he has seen a chiropractic physician and has had a number of treatments. I have received notes from chiropractic physician, who stated that he has 26 office visits with some improvement of his symptoms. However, the patient reports to me that he does continue to have significant pain. The patient did have MRI scans of the cervical and lumbar spine. MRI of the cervical spine performed on 05/22/2013 revealed a central disc herniation with annular tear at C5-C6 with ventral cord impingement, a broad based disc herniation at C6-C7 with anterior thecal sac indentation, and disc bulging at C3-C4 and C4-C5 with anterior thecal sac indentation. In addition, the patient has an MRI scan of the lumbar spine also performed on 05/22/2013 which did reveal disc bulging at L4-L5 and L5-S1 with encroachment of descending S1 nerve roots at L5-S1.
1. Persistent cervicalgia status post motor vehicle accident.
2. Cervical radiculopathy.
3. Persistent lumbago.
4. Lumbar radiculopathy.
The patient and I did have nice talk today regarding his pain and overall plan of care. He does have radicular symptoms to both his upper and lower extremities and I am therefore requesting authorization from the insurance company for nerve conduction studies of bilateral upper and lower extremities as well as needle EMG examination of bilateral upper and lower extremities to evaluate my patient’s numbness, tingling, weakness and pain and to rule out radiculopathy, plexopathy, traumatic peripheral neuropathy, or nerve entrapment syndrome. The study will help me to determine the level of the lesions and help with his medical management as well as help him to determine referral for possible cervical and lumbar epidural steroid injections or other specific treatment. Due to this patient cervical and lumbar MRI findings as well as his physical exam, I do feel that this study is medically necessary. It will also help me to determine the severity of his symptoms.
The patient has had persistent pain for a long period of time and I do feel that he would benefit from trigger point injections. We discussed this procedure in detail and the patient would like to have this procedure performed to try to alleviate some of his symptoms. Multiple trigger points were found on his physical exam. I am requesting authorization from the insurance company to perform trigger point injections.
In the meantime, the patient will continue to follow up with Dr. as directed. We did discuss that he will use ice 20 minutes at least twice daily and further discussed gentle home exercise. The patient will be using over-the-counter anti-inflammatory medications for his pain relief. We will readdress possible medication options at his next visit. We will have the patient follow up with me in two weeks’ time. He will call me with any questions or concerns prior to this.