Neck Pain Case Study
Amy is a 34-year-old female here today complaining of neck pain.
HPI
The patient tells me her symptoms started in early August. She had been away on vacation. She was sleeping on an air mattress. One night realized that the air mattress was not fully inflated, but slept anyway and she awoke the next morning, she was having some neck pain. She said initially she attributed just to sleeping wrong. She had pain for a couple of days. She took a few days worth of Advil and felt better. She said following that, the pain restarted without any specific injury or trauma that she can recall. It was severe enough that she was unable to move her head at all without significant pain. She was feeling very tight in the back of her neck. She has started having headaches from it as well. She came in to see Katy Lilly, MD in my absence on August 26th. Please see that note for complete details. It was recommended that she continue with stretches. She was given Percocet for pain, as well as Valium, to be needed, as a muscle relaxant and a five day burst of prednisone. The patient tells me that she only took the …show more content…
On exam, she does have pain over the cervical spine with palpation as well as with muscle spasm noted. I have recommended a C-spine x-ray, which I reviewed with her with the results are available. She was also given a referral for physical therapy, which has helped her in the past. She has used it for her neck. She was comfortable this plan. I did write her for more Valium 2 mg one at bedtime as needed #15 with no refills. I reviewed the use and side effects of the medication with her and she is aware of what to be monitoring for. She is aware of sedation effects and will not drive with it nor drink alcohol with it. The plan would be to have her follow up with me if she does not feel as though she is improving. Certainly sooner follow up if her symptoms are
HPI
The patient tells me her symptoms started in early August. She had been away on vacation. She was sleeping on an air mattress. One night realized that the air mattress was not fully inflated, but slept anyway and she awoke the next morning, she was having some neck pain. She said initially she attributed just to sleeping wrong. She had pain for a couple of days. She took a few days worth of Advil and felt better. She said following that, the pain restarted without any specific injury or trauma that she can recall. It was severe enough that she was unable to move her head at all without significant pain. She was feeling very tight in the back of her neck. She has started having headaches from it as well. She came in to see Katy Lilly, MD in my absence on August 26th. Please see that note for complete details. It was recommended that she continue with stretches. She was given Percocet for pain, as well as Valium, to be needed, as a muscle relaxant and a five day burst of prednisone. The patient tells me that she only took the …show more content…
On exam, she does have pain over the cervical spine with palpation as well as with muscle spasm noted. I have recommended a C-spine x-ray, which I reviewed with her with the results are available. She was also given a referral for physical therapy, which has helped her in the past. She has used it for her neck. She was comfortable this plan. I did write her for more Valium 2 mg one at bedtime as needed #15 with no refills. I reviewed the use and side effects of the medication with her and she is aware of what to be monitoring for. She is aware of sedation effects and will not drive with it nor drink alcohol with it. The plan would be to have her follow up with me if she does not feel as though she is improving. Certainly sooner follow up if her symptoms are