The patient is a 38-year-old female who was the restrained driver of a vehicle involved in a motor vehicle accident on May 30, 2013. She presents today for further evaluation and treatment of her injuries. Specifically, she reports pain to her neck, upper back, low back as well as both forearms and left wrist/hand. She does have a history of low back pain as well as left wrist/hand pain, but denies any prior history of neck or upper back pain. She reports that her low back and left wrist/hand pain were all significantly exacerbated by this new motor vehicle accident. The patient denies pain, weakness, numbness or tingling into her extremities with the exception of the bilateral forearm pain. She feels that forearm pain is a separate injury from holding on to the steering wheel tightly. The patient has been receiving chiropractic treatments and physical therapy with positive results, but is very frustrated as she continues to have significant pain. She also is frustrated that she has a history of being addicted to pain medications. Therefore, is unable to take pain medications for her severe pain at this time.
1. Posttraumatic cervical sprain/strain.
2. Posttraumatic thoracic sprain/strain.
3. Posttraumatic lumbar sprain/strain.
4. Bilateral forearm sprains.
5. Exacerbation of chronic left wrist/hand pain.
The patient and I did have a nice talk today regarding her pain and overall plan of care. She is very frustrated that she continues to have severe pain and is unable to take pain medications due to her past history. She repros that she has had trigger point injections in the past and that they have helped for her low back prior to low back injury. Therefore, she would like to try trigger point injections for her current pain. We will request approval from her insurance company prior to proceeding.
The patient has been attending physical therapy and receiving chiropractic treatments. She will continue to do so as they are providing at least some temporary relief to her symptoms. I am hopeful that this therapy will allow her to progress to more complete recovery as well.
Finally, I am recommending that the patient use ice 20 minutes at least twice daily and we did discuss gentle home exercise. She will follow up with me in one week’s time. She will call me with any questions or concerns prior to this.