MDM - Cervical Muscle Strain (Whiplash Injury) - Motor Vehicle Collision

[##]-year-old [male/female] with neck pain following a motor vehicle collision (MVC) with history and exam consistent with likely cervical muscle strain (whiplash injury).

Initial consideration in this patient included cervical spine fracture or dislocation, soft tissue injury to the chest, neck or torso, and cervical muscle strain among others.

Patient arrived to the ED following a [low/moderate] risk MVC [in cervical spine immobilization/and was placed in a cervical collar in triage/without indication for cervical spine immobilization in the field].  Cervical spine [could not be] cleared by [NEXUS criteria/Canadian C-Spine Rule] upon arrival in the ED.  Patient was noted to have a normal neurologic exam in the ED.  [CT/Plain films were obtained in the ED with no evidence of significant injury as noted above.]  Patient noted to have [right-/left-sided/bilateral] paraspinal muscle tenderness [with/without] associated muscle spasm.  Patient noted to have [no] evidence of contusions to the chest consistent with seatbelt injury.  No other significant tenderness or injury noted on exam with no indications for further imaging at this time.

Patient reported significant improvement with [treatment] prior to discharge from the ED.  We discussed return precautions, treatment [with analgesics/NSAIDs], and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.

https://www.mdcalc.com/canadian-c-spine-rule
https://www.mdcalc.com/nexus-criteria-c-spine-imaging