Right shoulder pain and low back pain

The patient is a very pleasant 43-year-old female who was a seat-belted driver in 2004. On February 18, 2013 at approximately 9 a.m., she was traveling with her friend, in the front seat. She was then hit on the passenger’s side door. She states at the time of the impact, she believes both arms were extended on the steering wheel and she managed to start hitting her brake prior to impact. She was ultimately transported Medical Center as well with her friend for evaluation and treatment. She subsequently underwent x-rays and some other type of test that she cannot remember. She was released from the hospital later that day. She has no history of low back pain nor any history of shoulder problems in the past.

ASSESSMENT:
This very pleasant, Bilingual 43-year-old female was involved in a motor vehicle accident on February 18, 2013 who has undergone care with improvement over the past few weeks.

IMPRESSION:
1. Right shoulder pain; most likely a combination of traumatic acromioclavicular joint pain in addition to referred pain from the right T3 through T5 zygapophyseal joints.
2. Mild discomfort of the subacromial bursa.
3. Mid low back pain; appears to be more somatic in nature.
4. Low back pain; Likely facet-mediated pain secondary to M.V.A.

PLAN:
I do not feel that any further imaging is warranted at this point. The patient’s examination was neurologically intact today and she admittedly is improving. She has good range of motion of the cervical spine in extension and rotation with no deficiencies noted.

I would like to see her continue. She continues to make meaningful improvement. I would like to see her back in four weeks for reevaluation and for assessment if further imaging is warranted. In the absence of neurological symptoms at this time, I do not feel that MR imaging is appropriate.

She seemed very happy with the visit today. I will see her back in four weeks for reevaluation.

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