Posttraumatic upper trapezius strain

The patient returns today for reevaluation of her pain. She reports slight improvement in her symptoms, but continued pain to her neck, upper back, low back as well as headaches. She reports pain shooting to the right shoulder region as well as weakness to the right shoulder region. She denies any new complaints. MRI scan of the cervical spine performed on 06/20/2013 revealed a herniated disc to the right at C4-C5 as well as multiple bulging discs and some stenosis at C5-C6. MRI of the lumbar spine performed on the same date revealed central disc herniations at L4-L5 and L5-S1.

IMPRESSION:
1. Posttraumatic cervical sprain/strain with possible radiculopathy.
2. Posttraumatic upper trapezius strain.
3. Posttraumatic lumbar sprain/strain with possible radiculopathy.
4. Posttraumatic cephalalgia.

PLAN:
Patient and I have a nice a talk today. We discussed additional treatment options such as trigger point injections, which we did discuss at her last visit. She is frustrated as her pain continues, but she is very needle phobic. However, she also does wish to try options to improve her pain. We decided that she will try another several weeks of physical therapy. I will see her back in two weeks and if she is not improved at that time, we will ask her for pre-certification from her insurance company to possibly do inject trigger point injections at her next visit.

I also discussed with the patient that I do feel that she could be a good candidate for epidural steroid injections as she does have herniated discs with radicular symptoms. She stated that it is extremely unlikely that she will have this procedure done due to her phobia to needles. Regardless, I feel that she would benefit from seeing my partner Dr. to discuss this option.

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