Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of cervical pain and stiffness following a motor vehicle accident (MVA) occurring [Time/Date]. Reports mechanism of injury consistent with rapid acceleration-deceleration forces. Symptoms include localized posterior cervical tenderness, restricted range of motion, and associated [headache/dizziness/paresthesia]. Denies loss of consciousness, focal neurological deficits, or bowel/bladder dysfunction. Pain intensity rated at [0-10]/10, exacerbated by cervical rotation and flexion.
Clinical Examination Findings
Physical examination reveals diffuse tenderness to palpation over the cervical paraspinal musculature and trapezius bilaterally. No midline bony tenderness or step-off deformity noted. Cervical range of motion is limited in all planes due to pain, specifically flexion and rotation. Neurological exam: Cranial nerves II-XII intact. Motor strength 5/5 in upper and lower extremities. Deep tendon reflexes 2+ and symmetric. Sensory exam intact to light touch. Spurlingโs test negative.
Treatment Protocol
Plan: 1. Conservative management with activity modification; avoid prolonged immobilization. 2. Pharmacotherapy: NSAIDs (e.g., Ibuprofen 400-600mg TID) and muscle relaxants (e.g., Cyclobenzaprine 5-10mg QHS) as needed for muscle spasms. 3. Physical therapy referral for gentle range of motion exercises and postural stabilization. 4. Application of ice/heat packs for 15-20 minutes every 4 hours. 5. Follow-up in [Number] weeks or sooner if neurological symptoms develop.