The patient is a 22-year-old male who was a restrained driver of a vehicle involved in a motor vehicle accident on May 3, 2013. He presents today for further evaluation and treatment of his acute injuries. Specifically, he reports that he has had pain to his neck as well as low back and headaches. He reports that his neck pain has become intermittent. He reports on occasion low back pain and reports that his headaches are currently resolved. He reports that he was evaluated in the emergency department the day following the injury. He reports that he had a thorough examination performed and was prescribed Valium and told to follow up with a specialist. He has been receiving physical therapy. He reports that he has seen chiropractic physician who prescribed MRI scans. MRI of the cervical spine revealed a disc bulge at C3-C4 with anterior thecal sac indention. MRI of the brain revealed an apparent abnormality within the pituitary gland area. He was therefore sent for a contrast MRI scan, which revealed no definite evidence for macroadenoma. It did reveal a high signal and a posterior pituitary, which was felt to likely represent prominent posterior pituitary neurosecretory granules. The patient denies pain, weakness, or numbness shooting into his arms or legs or additional complaints at this time.
1. Posttraumatic cervical sprain/strain.
2. Posttraumatic cephalalgia.
3. Posttraumatic lumbar sprain/strain.
The patient and I did have nice talk today regarding his pain and overall plan of care. He has improved with the therapy that he has been doing, but does continue to have pain especially to the neck region although intermittent and occasional low back pain. He reports that he was taking ibuprofen in the past, but it is not always effective enough. Therefore, he will stop taking it. We are trying a new prescription. He was prescribed Voltaren 75 mg one pill twice daily as needed. We did discuss GI precautions. This medication was called in. The patient will continue with physical therapy and continue seeing any other physicians that he has seen as directed. He will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. He does have significant trigger point injections to the bilateral upper trapezius muscles. I do feel the trigger point injections may be helpful for relieving his neck pain and for help him to prevent any additional headaches, which could recur in the future from this accident. Therefore, we will put him for pre-approval for trigger point injections to be done to his upper trapezius region. I will have the patient follow up with me in two weeks. He will call me with any questions or concerns prior to this.
In the office I did readdress the abnormal MRI scan of brain with the patient. I discussed with him that he should follow up with his primary care physician regarding the abnormalities noted in the pituitary gland region. He understands this and is present during this dictation and agrees to do so.