HISTORY OF PRESENT ILLNESS: The patient is a very pleasant right-hand dominant 63‑year-old woman who is a retired employee with the Department of Transportation. She lives in New York, but is currently visiting family in the Vail Valley. She plans on returning to New York in two weeks. Approximately two weeks ago, she awoke with left neck and shoulder pain. She denies any specific mechanism of injury. She has not had any symptoms like this before. She describes pain that originates in the middle of the left neck and can travel up into the base of the skull as low as down into her shoulder and arm. Over the past week, she is noticing more and more pain traveling into her hand as well as paresthesias into the top of her hand and left pinky. She denies any right-sided symptoms. The pain is not constant, but when it is present, it can be as high as a 10/10 on a visual analogue scale. Supporting her left arm with her right hand helps alleviate the pain. Sitting increases it. She is able to sleep at night as long as she lies on her left side. Laying on the right increases the pain. She has been taking ibuprofen 200 mg tablets two to three times a day. She saw Joel Dekanich, DC, yesterday and he referred her to me today. He was concerned that she may have a left cervical radiculopathy. He obtained x-rays today and they are available for my review. She denies any weakness, but does feel like the paresthesias are getting worse.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, history of TIA x2 without any residual effects, myocardial infarction with subsequent cardiac catheterization that the patient reports was normal, and hypothyroidism.
PAST SURGICAL HISTORY: Right shoulder surgery, right elbow surgery, cardiac catheterization, and thyroidectomy.
MEDICATIONS: Omeprazole, Synthroid, oxybutynin, metoprolol, atorvastatin, quinapril, bupropion HCL, aspirin 81 mg, levocetirizine, zolpidem tartrate as needed, valacyclovir as needed, and Nitrostat 0.4 mg (the patient has never had to take this).
RADIOGRAPHIC EVALUATION: AP, lateral flexion and extension views of the cervical spine were obtained in the office and are available for my review. There is mild spondylosis and disc degeneration throughout the cervical spine. There is diminished disc height at the C4‑5 level consistent with moderate disc degeneration. There is severe disc degeneration at the C5-6 and C6-7 levels with osteophytic ridging. There is no evidence of fracture. The patient is slightly lifted to the right. There is evidence of anterolisthesis or retrolisthesis noted.
PHYSICAL EXAMINATION: Vital Signs: Blood pressure is 132/90, pulse is 72 beats per minute, and respirations are 12 per minute.
Gait is normal. The patient stands with a mildly forward flexed posture and slightly listed to the right. She is cradling her left arm and her right hand and does appear to be in mild-to-moderate distress secondary to pain. Motor exam demonstrates slight weakness at 4/5 in left elbow extension, left wrist flexion and left finger abduction. Remaining strength is 5/5 in the upper extremities. Sensation is diminished to light touch in left C7 dermatomal distribution. Reflexes are 1/4 in the bilateral biceps and brachioradialis, 1/4 in the right triceps and difficult to elicit in the left triceps. Cervical range of motion is reduced predominantly in flexion and extension secondary to pain. Spurling’s test is positive on the left with reproduction of left shoulder and arm pain. Pain is increased with axial compression and elevated with distraction.
- Acute left neck, shoulder and arm pain with paresthesias.
- Probable right C7 or C8 radiculopathy.
- C5-6 and C6-7 severe disc degeneration with osteophytic ridging. I am concerned there may be a protrusion at the C6-7 level contributing to the patient’s current symptoms.
- I recommend the patient starts taking dexamethasone 4 mg one p.o. q.12h. with food for five days. Hopefully, this will help diminish any inflammation and will help alleviate her pain. Medication side effects were discussed. I advised her to closely monitor her blood pressure as she does have a history of hypertension.
- I recommend the patient take tizanidine 2 mg one-two tablets every eight hours as needed for spasm. Medication side effects were discussed. I prescribed quantity of #20 with one refill. I also advised her to try Extra Strength Tylenol one-two tablets every six to eight hours as needed for spasm. I told her not to take more than four tablets in a 24-hour period.
- We discussed obtaining an MRI of the cervical spine. The patient is going to see how she does throughout the night. If her symptoms are not improving, I would recommend she proceed forward with an MRI of the cervical spine. She reports being mildly claustrophobic; therefore, I recommend she take Valium 5 mg one p.o. one hour prior then one p.o. 10 minutes prior as needed for the MRI. I prescribed quantity #2 with 0 refills. I advised the patient to have a driver as she cannot drive while on these medications.
- Also advised the patient to follow up with me within the next one-two weeks if she is not improving. At that point, she will get the MRI and we would discuss the findings and treatment recommendations. The patient understood and agreed with this plan. I spent approximately 30 minutes in face-to-face time with this individual.