Cervical herniated disc

The patient returns today for reevaluation. He reports continued pain to his neck as well as his left upper extremity. He denies any new complaints since his last visit.

IMPRESSION:
1. Cervical herniated disc.
2. Cervical radiculopathy.
3. Posttraumatic cervical sprain/strain.

PLAN:
The patient and I have another nice talk today regarding his pain. We had previously discussed trigger point injections which now had been pre-approved from his insurance carrier. We readdressed the risks and benefits of this procedure verbally and the patient decided to proceed. A solution of lidocaine 1% 4 cc, Marcaine 0.25% 1 cc and Celestone 30 mg per 5 mL was used. Injections were done to the left upper trapezius, left lower cervical paraspinal region, and left rhomboid region. The patient tolerated the procedure well and there were no complications. The patient will continue with therapy and continue to see his chiropractic physician. We readdressed home exercise and ice. He will call me with any questions prior to our next visit in two weeks.

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