Thank you for referring to me. As you know, she is a 57-year-old right-handed female who is here for initial evaluation of pain in the neck and low back after a MVA on 04/23/2011. The patient was a restrained driver of a car. She was crossing Highway 35 in Laurence Harbor at a green light, the other driver took illegal left turn consequently hitting her. The patient was hit from the left side. Her vehicle was driving at a speed of approximately less than 20 miles, although the other vehicle at a speed of 50 miles. After the accident, the patient was taken to the hospital. She followed up with Dr., which she sees regularly. The patient had history of back and neck pain from a previous accident in 1993, but for the last several months before the accident, the patient was doing a lot better after seeing Dr.. Since the accident, her neck and back pain has become worse. Her pain level is about 7 to 8/10. The pain in the back goes down to both legs with tingling and numbness in both legs. Her legs feel weak, especially on the left side. She complains of tingling and numbness in the both hands and she has to continue to shake her hands to reduce the numbness. She also had an MRI done of C-spine, which showed disc herniation at C4-C5, C5-C6, and C6-C7 and MRI of the LS-spine, which showed disc herniation at L5-S1 and anterolisthesis of S1 on S2. The patient’s pain is achy, burning, and numb. Stretching seems to make a little better. Sitting, lying down, and walking makes the pain worse. The patient denies any bowel or bladder involvement or any pudendal numbness.
Myofascial pain syndrome.
Worsening of carpal tunnel syndrome.
Positive Tinel sign of bilateral hands.
I will request authorization from the patients insurance company for an EMG/NCV study of bilateral upper and lower extremities es to differentiate between plexopathy and lumbar radiculopathy, also to rule out double crush syndrome. I will start the patient on Ultracet tablet three times a day p.r.n. for pain and Flexeril 10 mg p.o. q.h.s. to help in pain. The patient is ready to follow up with Dr. as advised.