A 68-year-old female named Nancy was riding in the front passenger seat when the car was involved in a motor vehicle accident. Nancy knew that she was hurt, but there was no ambulance at the scene - so Nancy went home, hoping to feel better. Unfortunately, after several days, she realized that the pain in her neck, back, right shoulder and headaches, was not going away on its own, so she visited an MSR-supported physiatrist.
While Nancy noted her specific complaints, a careful history determined the she also had pain radiating into her right arm, as well as weakness in that arm. What's more, Nancy's shoulder pain was accompanied by difficulty in raising her shoulder, and her low back pain and episodic headaches persisted. Pre-existing hypertension and diabetes further complicated her medical history.
The physician performed a thorough physical examination-including objective testing and comparison to normal standards-confirmed Nancy's loss of range of motion, motor strength, and sensory deficits.
Under in-office physician guidance, Nancy started a course of physical therapy, and the physician ordered diagnostic studies to delineate the extent of the her injuries. Nancy's MRI results confirmed the initial diagnosis of multiple disc herniations, as well as rotator cuff tear.
The physician referred Nancy to an orthopedic surgeon, who determined that surgery wasn't necessary and that she should continue her course of conservative treatment.
Upon follow up, Nancy continued to have pain in her neck and back with radicular signs and symptoms. As a result, the physician performed Electrodiagnostic studies, which helped fully document her injury and enabled appropriate referral for pain management evaluations and treatments.
Ultimately, Nancy completed a five-month course of physical therapy and had improved to the point where her physician could discharge her safely, encouraging her to return if her symptoms worsened. Because of the comprehensive care that Nancy received from her MSR-supported physician, Nancy made a significant recovery from the multiple injuries she suffered and was able to return to work. This made Nancy (and her physician) very happy.
Case study by David Delman, M.D.
DHD Medical, PC