Posttraumatic lumbar sprain/strain

CHIEF COMPLAINT:

Neck pain, low back pain, and headaches with lower extremity pain.

HISTORY OF PRESENT ILLNESS:

The patient is a 40-year-old male who was a restrained driver of a vehicle involved in a motor vehicle accident today. He presents today for further evaluation and treatment of his acute injuries. Specifically, he reports pain to his neck and low back. He also reports headaches with disorientation. He reports that his right knee hit something in the car and now has right knee pain. He was having right ankle pain. He reports that his right ankle pain had subsided. He also was having some chest pain and pain down the right upper extremity, but reports that this has disappeared as well. He denies hitting his head or any loss of consciousness. He does state that he still does not look quite back to himself. The patient denies any prior history of similar symptoms with the exception of some sciatica, which occurred from a prior motor vehicle accident, which was many years ago. He reports that he has been pain free for at least 10 years prior to this accident.

PAST MEDICAL HISTORY:

The patient denies.

PAST SURGICAL HISTORY:

The patient denies.

DRUG ALLERGIES:

No known drug allergies.

CURRENT MEDICATIONS:

None.

SOCIAL HISTORY:

The patient denies tobacco, alcohol or illegal drug use. He works doing online marketing.

FAMILY HISTORY:

Noncontributory.

REVIEW OF SYSTEMS:

As above only.

PHYSICAL EXAMINATION:

General: Alert and oriented x3. HEENT: Normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft and nontender. Extremities: No clubbing, cyanosis, or edema. Neuromuscular examination: Sensation is intact in C5 to T1 and L2 to S2 dermatomes bilaterally. Deep tendon reflexes are 2+ bilaterally in biceps, triceps, and brachioradialis, patella and Achilles.

Motor strength is 5/5 bilateral for shoulder abduction, elbow flexion, elbow extension, wrist extension, finger flexion, and finger abduction; 5/5 bilaterally for hip flexion, knee extension, ankle dorsiflexion, long toe extension, and ankle plantar flexion. Right knee range of motion is full. There is pain to palpation of the knee joint in general without localization. Right ankle range of motion is full.

There is no pain to palpation of the chest or sternum. Spasm is noted to bilateral suboccipital musculature. Range of motion is reduced to cervical as well as thoracolumbar spine. Spasm and rigidity is noted to bilateral cervical and lumbar paraspinal musculature.

IMPRESSION:

  1. Posttraumatic cervical sprain/strain.
  2. Posttraumatic lumbar sprain/strain.
  3. Posttraumatic cephalalgia.
  4. Right knee contusion/possible sprain.

PLAN:

The patient and I did have nice talk today regarding his pain and overall plan of care. My biggest concern is his headaches and disorientation. For this reason, I am sending him for an MRI scan to be done today. I discussed with the patient that if he is no table to get this MRI scan performed today, then he needs to go to emergency department for further evaluation and treatment. In addition, we discussed that he was initially having some chest pain with pain radiating to his right upper extremity. He no longer has any of these symptoms. I discussed with him that if these were present, he does need to go to emergency department for further evaluation and a cardiovascular workup. He is present during this dictation and agrees with this and the prior statement regarding his headaches and disorientation. He will have x-rays done of the cervical and lumbar spine today. I am referring him to physical therapy as well as the chiropractic physician in this office to evaluate and treat him. Initially, he will receive therapeutic modalities and a new type of chiropractic adjustments. I am also prescribing two medications. He was prescribing naproxen 500 mg one pill twice daily for anti-inflammatory effects. We did discuss GI precautions. In addition, he was prescribed cyclobenzaprine 10 mg one pill before bed as needed to help reduce spasm. We discussed that he will not try drive or operate machine while taking this medication. I will have him follow up with me in two weeks’ time. He will call with me with any questions or concerns prior to this.

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