Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for initial evaluation following a motor vehicle accident (MVA) occurring [Time/Date]. Patient reports sudden neck hyperextension/hyperflexion mechanism. Chief complaints include localized cervicalgia, paracervical muscle spasms, and restricted range of motion. Denies radicular symptoms, paresthesia, or focal neurological deficits. Pain is rated [0-10] and exacerbated by cervical rotation.
Clinical Examination Findings
General: Patient is alert and oriented, in mild distress due to pain. Neck: Inspection reveals no obvious deformity or ecchymosis. Palpation demonstrates significant tenderness to the paracervical musculature and trapezius bilaterally. Range of motion (ROM) is limited in all planes due to pain. Neurological: Cranial nerves II-XII intact. Strength 5/5 in upper extremities. Deep tendon reflexes 2+ and symmetric. No sensory deficits noted.
Treatment Protocol
Plan: 1. Conservative management initiated. 2. Prescribed NSAIDs (e.g., Ibuprofen or Naproxen) for inflammation and pain control. 3. Muscle relaxants (e.g., Cyclobenzaprine) as needed for nocturnal spasms. 4. Application of ice packs for 20 minutes every 2-3 hours for the first 48 hours, then transition to heat. 5. Referral for physical therapy to initiate gentle range-of-motion exercises. 6. Follow-up in 2 weeks or sooner if neurological symptoms develop.