HISTORY OF PRESENT ILLNESS:
The patient returns today for reevaluation. He reports excellent results from the injections, which were done at last visit. He reports substantial improvement to his neck pain, right shoulder pain although reports continued pain if he sleeps on the area the wrong way. He denies any significant pain shooting to his right upper extremity. He does report some new dizziness, which occurs primarily when walking.
General: Alert and oriented. HEENT: Corrective lenses. Chest: Normal respiratory effort with good chest wall excursion. Abdomen: Soft and nontender. Extremities: No clubbing, cyanosis, or edema. Neuromuscular examination: Range of motion to the cervical spine is reduced. Mild spasm is noted to the right cervical paraspinal musculature as well as right upper trapezius. Right shoulder range of motion is reduced.
- Cervical radiculopathy.
- Multiple cervical herniated
- Cervical degenerative disc disease.
- Myofascial pain.
- Right rotator cuff tear.
The patient did very well with the injections, which were performed at his last visit. He has not seeing Dr., who I did refer to primarily to discuss epidural steroid injections. However, as his pain is substantially reduced, I do not feel that he needs to undergo this procedure at this time. However, I will continue to follow the patient along to make sure that his symptoms do not return. If they do, we will address him seeing my partner Dr. Yen to discuss interventional procedures. He had a similar discussion regarding his right shoulder, which he has been in search of an orthopedic surgeon for. As far as dizziness, I told the patient that he needs to discuss this with his medical physicians that are treating him to ensure that there is no medical reason for this. I will have the physical therapist address this as he is receiving physical therapy for other reasons. The patient will continue with his current medication, which he believes is tramadol. He will call me with any questions or concerns prior to our next visit.