Continued pain to her neck and upper back.

HISTORY OF PRESENT ILLNESS:

The patient returns today for reevaluation. She report continued pain to her neck and upper back. She does report exacerbations and remissions of pain but no significant change since our last visit. She did an MRI scan performed. The MRI scan did reveal a small herniated disc at C6-C7. She reports continued pain to her right upper extremity. She does report some numbness to the right upper extremity. She denies any new complaints.

PHYSICAL EXAMINATION:

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: Sensation and motor intact to bilateral upper extremities. Range of motion of cervical spine is reduced. There is pain with cervical extension. There is positive Spurling’s maneuver. Trigger points are noted to the cervical paraspinal musculature, right upper trapezius muscle, and right scapulothoracic region.

IMPRESSION:

  1. Persistent posttraumatic cervicalgia.
  2. Cervical radiculopathy.
  3. Cervical herniated disc.
  4. Myofascia pain secondary to all the above.

PLAN:

The patient and I did have nice talk today once again regarding her pain and overall plan of care. We did discuss treatment options and discuss the risks and benefits of trigger point injections. The patient decided to proceed with the procedure with a solution of lidocaine 1% 3 cc and 1.5 cc of betamethasone 30 mg per 5 mL was used. Injections were done to the right upper trapezius, right cervical paraspinal region, and right scapulothoracic region. A total of six injections were performed. The patient tolerated the procedure well and there were no complications. The patient will continue with physical therapy and continue to follow up with her other physicians. She will continue with ice and home exercise. I will have her follow-up with me in two weeks’ time to evaluate the success of these injections. We also discussed electrodiagnostic testing, which I think will be very beneficial for her. However, the patient does not wish to undergo any additional testing at this time. We will try a series of trigger point injections as mentioned above. If these are unsuccessful, we will discuss the possibility of her seeing my partner Dr. to discuss interventional procedures.

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