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I think he was maybe going five or ten miles an hour. And were you wearing your seatbelt at the time? Yeah. And so you said you didn't go to the hospital or anything because you didn't feel any pain initially? No. So when exactly did did the pain start? About how many hours after the accident? I would probably say maybe [DURATION] [DURATION] [DURATION] [DURATION] after. I think maybe I was just in shock at first, and so I didn't really feel any pain or anything. All right. And where is it bothering you specifically? Can you pinpoint a specific area on your neck? It's mostly just the back of my neck and on the sides of my neck. Both sides? Yes. And did you hear any pops or have any numbness or tingling that occurred during the accident? No. And is there anything that's making the pain worse? Mostly when I bend my head forward and try to turn it to the left, it kind of. I notice it's a little uncomfortable. Anything you've noticed that's helping it? I took some [DRUG] and I put ice on the back of my neck, and that helped a little bit, but it still hurt. It still hurt. And how much [DRUG] are you taking? I took [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] [DURATION] [DURATION] or so since then. I'm just taking some notes, so that way, when I go talk to [PERSON_NAME]. [PERSON_NAME], I can be thorough and let her know everything you're telling me. So it's worse whenever you're bending forward and to the side, to the left. Is that correct? Yes. All right. And can you describe the pain? To me? It just feels like a tight kind of dull Pain. Okay. So tight and. And dull. And is this pain radiating or moving anywhere? Not really. It just goes up and down the back of my neck. So nothing coming down into the arm? No. Okay. And on a scale of 1 to 10, with 10 being the worst pain, where would you say you're at? Probably around a 6 or a 7 out of 10. Especially when I try and bend forward and turn my head. And is it a constant pain? Yes. And so. But it'll get worse whenever you bend forward and turn to the left. Okay. And would you say since the accident, since that evening, has it been constant or is it getting worse? Better? What would you say? It feels like it's getting worse, but I don't know if that's because the [DRUG] is not working. Well, I'm glad you came in. The [DRUG] [DRUG] [DRUG] stuff's not working and we can do an exam and make sure there's nothing we're missing. And if we need to possibly do some [MEDICAL_PROCESS] [MEDICAL_PROCESS] and we'll get onto that later. Okay? Okay. And as far as your past medical history, have you ever had a [INJURY] [INJURY] before? No. No. So you've never had problems with your neck? No. Okay, that's good to know. And any medical conditions that you're currently being treated for or that you've ever been treated for? I have [MEDICAL_CONDITION] and I take medicine for that. Okay. That's about it. Ever been [MEDICAL_PROCESS]? No. Ever had any [MEDICAL_PROCESS]? I had my [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] when I was a kid. I think I was probably [PERSON_AGE]. And as far as medications, you said you take the [DRUG] [DRUG] [DRUG] [DRUG] and then you take something for [MEDICAL_CONDITION]. What do you take for your [MEDICAL_CONDITION]? I take [DRUG]. Do you just take that as needed. And do you take any other medications? I take a [DRUG] or a [DRUG] for [MEDICAL_CONDITION]. Okay. What about any [DRUG] [DRUG], [DRUG]? I take a [DRUG] and I always like to ask all my patients, any recreational drug use? No, none. And are you [MEDICAL_CONDITION] [MEDICAL_CONDITION] any medications? I am. I'm [MEDICAL_CONDITION] [MEDICAL_CONDITION] [DRUG]. And what happens when you take [DRUG]? I break out in a rash. In a rash. Will we be sure never to give you [DRUG] for anything? Thank you. And as far as family history, any medical conditions in the family with your mom and dad? My mom, she's pretty healthy. She has [MEDICAL_CONDITION], though, and it's pretty under control. Good. My dad has [MEDICAL_CONDITION] [MEDICAL_CONDITION], but he takes medicine for that. Any brothers or sisters? I have A brother. And he's healthy? He's healthy. He doesn't have any conditions or anything. And no one's ever had problems with joints or [MEDICAL_CONDITION]? No, no, no. And I always like to just get an overview of my patients, kind of get to know them a little better. What do you do for a living? I'm an [OCCUPATION] [OCCUPATION]. Oh, where do you work? I work for the [ORGANIZATION] [ORGANIZATION] [ORGANIZATION] [ORGANIZATION]. Oh, wow. That must be fun. Yeah. You've been doing it for a while? Yeah, for [DURATION] [DURATION] [DURATION]. Stressful or pretty? It's not very stressful at all. That's good. And are you [MARITAL_STATUS]? I am, yeah. Congratulations. Thanks. Do you have any children? No, not yet. No children? No. All right. And so do you have hobbies that you like to do? I do. I like to cook and I like to garden. It's been kind of difficult to garden because I can't lean forward as much for the past [DURATION] [DURATION]. Yeah. Can be frustrating when you can't do the things you enjoy. Any tobacco use? I smoke probably maybe half a pack a day, if that. And how long have you been smoking? I want to say maybe [DURATION] [DURATION] or so. Any alcohol use? Occasional. I'll have a glass of wine with dinner maybe once a [DURATION]. Okay. All right, Well, I believe I got all the information I needed from you, so we're going to go ahead and move on to the [MEDICAL_PROCESS] [MEDICAL_PROCESS] portion. So what I'm going to do is I'm just going to have you take a seat up here. All right. For the [MEDICAL_PROCESS] [MEDICAL_PROCESS], I'm going to go ahead and listen to your heart and lungs and make sure those sound nice and clear. Okay. So I'm going to slide this down and just breathe normal. I'm going to take a big, deep breath. And again, again. And last. Good. And so I'm just going to do a [MEDICAL_PROCESS] [MEDICAL_PROCESS] here and [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS] [MEDICAL_PROCESS]. Let me know if there's anything that's tender. Tender? Everywhere. Everywhere. Okay. And I'm going to work my way down and I'm going to check the range of motion in your neck. So what I want you to do is try to put your chin down to your chest about as far as I can go. And then looking up to the ceiling. Pretty stiff. Okay. And what about turning and looking over to the shoulder? All right. And turn and look to that shoulder for me right there. And then ear to your shoulder. Trying to touch your ear over to your shoulder. And then ear to the other shoulder. That's as far as. All right. And I'm going to go ahead and check just some reflexes. This will kind of tell me if there's any nerves that are involved. So just relax your arm. And we're going to rest your arm right here on your lap. Just relax. And I'm going to do the same thing on this arm. Just relax your arm and just relax. And then last one, just let your arm hang. And now I'm going to test and see how strong you are. So place your arms like this for me and don't let me move your arms. Good. And arms up. Don't let me push them. Good. And fingers out for me. Don't let me squeeze them. And fingers together and try to push them out. All right. If it's okay with you. As an [OCCUPATION] [OCCUPATION], we've learned some treatments, so I'm going to do some [MEDICAL_PROCESS] [MEDICAL_PROCESS] to try and break up some of the tension that you're having. If that sounds okay, I'm going to hurt this out. No, it's not going to hurt. And if there's any pain, I want you to let me know. And so I'm just going to do just very gentle. It's called [MEDICAL_PROCESS]. Just kind of slowly up. And if this is something that you do get some relief from after this evening, then you can come back and we can be a little more aggressive. But since the class was just [DURATION] [DURATION] ago, I want to be very gentle. I'm just going to hold this right here. All those muscles that are tight and spasming right now attach right up where my fingers are at. So I'm just trying to get them to relax and loosen. So this is supposed to relax all the muscles? Yep. Okay. All right, I think that'll be enough for today. I don't want to do too much since it was such an [INJURY] [INJURY]. So I'm going to go ahead and help you up and then I'm going to go ahead and summarize everything that you told me from earlier, if that's okay. Would you prefer sitting back down in the chair? Sure. Okay. So you started having some neck pain [DURATION] [DURATION] ago after a motor vehicle accident. You were rear ended, but you were wearing your seatbelt. You didn't hear any pop or have any numbness or tingling that occurred, and it's just been real tight for the past [DURATION] [DURATION], real constant. But it's worse whenever you flex your head down or turn to the left, Is that correct? Yes. And as far as your past medical history, you just have [MEDICAL_CONDITION] and you're taking some medication for that. Okay. And you're not [MEDICAL_CONDITION] [MEDICAL_CONDITION] anything? [DRUG]. Excuse me? Yes, that's right. You are [MEDICAL_CONDITION] [MEDICAL_CONDITION] [DRUG]. All right, what I will do is I will go talk to [PERSON_NAME]. [PERSON_NAME] and. And then we will be back in to put together a treatment option plan for you. Any other questions or concerns you have for me today? No, I don't think so. Just want to feel better. All right. Well, that is our main goal, so I'm glad you came in today. Great. Thank you. Thank you.", |
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| "credit_card_cvv", |
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| } |
