Thoracolumbar facet syndrome

The patient is a 39-year-old female who was a restrained driver of a vehicle involved in a motor vehicle accident on September 7, 2011. She presents today for further evaluation and treatment of her injuries. Specifically, she reports neck pain, mid back pain and low back pain. She reports that she was treated by Dr. for her neck pain with trigger point injections and has had significant relief. However, she now reports an exacerbation of mid back pain and low back pain. Overall, she has had chiropractic treatments as well as physical therapy in addition to above-mentioned trigger point injections. The patient denies pain, weakness, or numbness shooting to her arms or legs or additional complaints at this time.

IMPRESSION:
1. Persistent posttraumatic cervicalgia.
2. Persistent posttraumatic thoracic pain.
3. Persistent posttraumatic lumbago.
4. Thoracolumbar facet syndrome.

PLAN:
The patient and I did have nice talk today regarding her pain and overall plan of care. We discussed a number of treatment options including continued physical therapy. She will continue with physical therapy, which she is attending today. She will also use ice 20 minute at least twice daily and we did discuss gentle home exercise. We also discussed medication options and injection options. She prefers not to be on medications if possible and does not wish to have an additional trigger point injections as she found them uncomfortable and does continue to have some neck pain. She is interested in exploring interventional procedures. She may be a candidate for facet injections or other interventional procedures. I am referring her back to see Dr. to discuss for options. She will call me with any questions or concerns.

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