Myofascial pain

The patient returns today for reevaluation. He reports continued pain to his right shoulder and less pain to his neck. He denies any new complaints. He does report that he had a stent placed one week ago.

IMPRESSION:
1. Cervical radiculopathy.
2. Multiple cervical herniated discs.
3. Cervical degenerative disc disease.
4. Myofascial pain.
5. Rotator cuff tear.

PLAN:
The patient and I had another nice talk today. He did respond well to trigger point injections previously. Injections were done today to the right upper trapezius, right deltoid, and lower cervical paraspinal musculature. A solution of lidocaine 1% and a small amount of Celestone was used. The patient tolerated the procedure well with no complications. The patient will continue to follow up with his other physicians for his medical issues. He will follow up with me in two weeks’ time.

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