Multiple cervical degenerative disc disease

The patient is a 71-year-old male with a long history of neck and shoulder pain. He reports the pain began approximately in 1985. He denies any specific inciting event or trauma. He does report pain to the neck as well as the right shoulder and reports pain shooting down the right upper extremity at times as well as occasional numbness and tingling to the entire right upper extremity and significant weakness to the right upper extremity at times. He has seen a number of physicians including at least two orthopedic surgeons for his shoulder. The most recent orthopedic surgeon who did an injection and felt that patient should have surgery to the right shoulder. patient prefers not to have surgery if possible. Patient has had MRI scans performed at his shoulder and cervical spine. MRI of the right shoulder, which was performed on June 1, 2013, revealed a right rotator cuff tear, which was felt possibly be chronic as well as osteoarthritis of the acromioclavicular joint and a small fluid subacromial/subdeltoid bursa. It also revealed findings, which were suggestive of a partial thickness intrascapular, long head of the biceps tendon tear and other normal variant versus ALPSA lesion. MRI of the cervical spine which was preformed on June 1, 2013 revealed multilevel degenerative disc disease with multiple levels demonstrating disc herniations, the most severely effected being C3-C4 level where there is a large extruded disc towards the right, but there was a moderate spinal stenosis and slight impingement/flattening of the lateral aspect of the cervical cord.

1. Cervical radiculopathy.
2. Multiple cervical degenerative disc disease.
3. Myofascial pain.
4. Right rotator cuff tear.

The patient and I did have nice talk today regarding his pain and overall plan of care. We discussed a number of different treatment options. I do think that the patient should see my partner Dr. to discuss epidural steroid injections. He does have radicular symptoms and an MRI scan, which correlates. I also recommended to the patient that he find another orthopedic surgeon to specifically evaluate the right shoulder. He was seeing Dr. but reports that Dr. no longer takes his insurance. He has another physician, which is searching to find an appropriate orthopedic surgeon for him. The patient reports that he does have medications on hand, which he is taking for his pain. He cannot remember the name but reports that it is some type of pain medication. He will continue to take these as needed.

The patient and I did discuss trigger point injections. We discussed the risks and benefits of the procedure. We did an injection of lidocaine 1% 4 cc and Kenalog 40 mg/mL 1 cc. Injections were done to the right upper trapezius, right scapulothoracic region, lower right cervical paraspinal region and some of the musculature around the right shoulder. A total of five injections were performed. The patient tolerated the procedure well. There are not complications. The patient will follow up with me after he sees my partner Dr. So, we can all agree on appropriate course of future option. In the meantime, he will continue with therapy. He will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. I have written a new prescription for the patient to continue with physical therapy.


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