Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents following a motor vehicle accident (MVA) occurring [Date/Time]. Mechanism of injury involved [rear-end/side-impact] collision with sudden acceleration-deceleration forces. Patient reports onset of neck pain, stiffness, and occipital headache immediately following the event. Denies loss of consciousness, paresthesia, or focal weakness. Pain intensity is [0-10]/10, exacerbated by cervical rotation and flexion.
Clinical Examination Findings
Cervical spine inspection reveals no obvious deformity or ecchymosis. Palpation demonstrates significant paraspinal muscle tenderness and hypertonicity from C2 to C7 bilaterally. Range of motion (ROM) is restricted in all planes due to pain, specifically flexion and rotation. Neurological exam: Cranial nerves II-XII intact. Upper extremity strength 5/5 bilaterally. Deep tendon reflexes 2+ and symmetric. No sensory deficits noted in dermatomes C5-T1. Spurlingโs test negative.
Treatment Protocol
Initiate conservative management for acute whiplash. Prescribe NSAIDs for inflammation and pain control. Recommend short-term use of soft cervical collar if needed for comfort, but advise against prolonged immobilization. Recommend application of ice packs for 20 minutes every 2-3 hours for the first 48 hours, followed by heat therapy. Refer for physical therapy to initiate gentle range-of-motion exercises and postural education.