Chronic cervicalgia.

CHIEF COMPLAINT:

Neck pain and low back pain.

HISTORY OF PRESENT ILLNESS:

The patient is a 67-year-old male with a long history of neck and low back pain with pain to his upper and lower extremities. He reports that his neck pain has been present for about 10 years. He initially was uncertain whether there is any specific inciting event or trauma, but does relate a softball injury where he threw the ball and believes that this may have caused some of the symptoms to his right upper extremity. He does report radiation of pain to both upper extremities but does report that right side is greater than left. He does report tingling to bilateral upper extremities as well as a weakness to the right upper extremity. He has had an MRI scan of the cervical spine with the most recent being on August 6, 2012. This did reveal a central disc herniation at C6-C7 contacting the ventral surface of the cervical cord as well as moderate annular bulges from C3-C4 to C5-C6. He has been treated with physical therapy. He denies any type of injection procedures or other medical treatment. The patient also reports a long history of low back pain and reports that this occurred about 30 years ago and thinks that this may have begun falling a lifting type of injury. He does report radiation of pain to the right lower extremity as well as numbness and weakness to the right lower extremity. He also had an MRI scan, which did reveal mild degenerative disc changes. It also revealed disc bulging with annular tear essentially at L5-S1. An MRI scan of the right shoulder was also been approximately one year ago, which revealed rotator cuff tendonitis as well as degenerative joint disease of AC joint with impingement.

PAST MEDICAL HISTORY:

Hypertension. Right hip injury from age 13.

PAST SURGICAL HISTORY:

The patient denies.

DRUG ALLERGIES:

No known drug allergies.

CURRENT MEDICATIONS:

Lisinopril and over-the-counter Aleve.

SOCIAL HISTORY:

The patient denies tobacco, alcohol, or illegal drug use. He reports that he did quit tobacco about five years ago. He is retired.

FAMILY HISTORY:

Noncontributory.

REVIEW OF SYSTEMS:

As above only.

PHYSICAL EXAMINATION:

General: Alert and oriented. HEENT: Normocephalic and atraumatic. Chest: Normal respiratory effort with good chest wall excursion. Abdomen: Soft and nontender. Extremities: No clubbing, cyanosis, or edema. Neuromuscular examination: Sensation is intact in C5 to T1 and L2 to S2 dermatomes bilaterally. Deep tendon reflexes are 2+ bilaterally biceps, triceps, brachioradialis, patella, and Achilles.

The motor is 5/5 bilaterally for hip flexion, knee extension, ankle dorsiflexion, long toe extension, and ankle plantar flexion; 5/5 bilaterally for shoulder abduction, elbow flexion, elbow extension, wrist extension, finger flexion, and finger abduction. Range of motion is significantly reduced to the cervical and thoracolumbar spine. Spasms and rigidity is noted to the right greater than left cervical paraspinal musculature as well as right greater than left lumbar paraspinal musculature. Trigger points are noted to the right cervical paraspinal musculature, right lumbar paraspinal musculature, and right upper gluteal paraspinal musculature, as well as pain to sacroiliac as well as triggers, points to the right sacroiliac region. There is a positive straight leg raise test on the right. Spurling’s maneuver was negative. Right shoulder range of motion is reduced. There is pain with external rotation. There is a pain to palpation of the anterior joint as well as the biceps tendon insertion.

IMPRESSION:

  1. Chronic cervicalgia.
  2. Cervical radiculopathy.
  3. Cervical herniated disc.
  4. Chronic lumbago.
  5. Lumbar radiculopathy.
  6. Right shoulder rotator cuff tendinosis.

PLAN:

The patient and I did have a nice talk today regarding his pain and overall plan of care. We discussed a number of treatment options and decided to proceed with injections. I have discussed with the patient that I believe that he may have several mechanism causing his pain including herniated discs, myofascial pain, and rotator cuff pathology. As his right upper extremity and shoulder region is possibly causing the most pain today, we decided to begin with an injection to the right shoulder. A solution of lidocaine 1% 2 ccs, and betamethasone 30 mg per 5 mL 1 cc was used. The injection was done to the right shoulder as well as into the insertion of the biceps tendon. The patient tolerated the procedure well. There were no complications. We did discuss the risks and benefits of the procedure prior to proceeding verbally. We did discuss medications. Presently, he does not wish to begin any new medications.   He will use ice 20 minutes at least twice daily to his neck, back, and right shoulder. He will continue with therapy and I did write him a new prescription for physical therapy. The patient and I discussed that I will see him back in two weeks’ time. If the injection to the shoulder does not help substantially, we will consider trigger point injections into the cervical spine. Regardless, we will most likely initiate trigger point injections for the lumbar spine as we did not address this today. We also discussed that if trigger point injections and joint injections do not provide significant relief to his symptoms, we will most likely refer him to my partner Dr.  for discussion about interventional procedures such as epidural steroid injections. I will see the patient back in two weeks’ time. He will call me with any questions or concerns prior to this.

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