Pain in her bilateral neck, bilateral head

The patient is a 55-year-old right-handed white female who comes for the first time with the chief complaint of pain in her bilateral neck, bilateral head, moving towards the frontal area and towards her bilateral ears. This has been going on for about 30-35 years on and off. This last episode started about two weeks ago causing pain in her head with even light touch almost at the level of the allodynia. She complains of pain which is even brushing her hair. The patient also complains of pain in her right upper extremity with some numbness in her forearm around the area of musculocutaneous median nerve and part of the ulnar nerve as well. Additionally, she complains of headache related to this neck pain. Although of not immediate concern currently, the patient also complains of back pain and bilateral feet pain. She claims that she has had neuroma resection and a nerve resection and one other surgery on her right foot by a podiatrist many years ago and has had numbness and pain on the left side as well but is very scared to get any chronic procedure because at the time of her first surgery, she states that she has been in a wheelchair. The patient claims that her pain is predominantly in regards to her neck and head pain. She claims that her pain is predominantly intermittent. She has had no procedures on her neck at any point.

PAST MEDICAL HISTORY:
Significant for rheumatoid arthritis and idiopathic thrombocytopenia. She claims her platelet count is about 64,000. She does see a hematologist/oncologist in Freehold. She also has a history of low vitamin D.

CURRENT MEDICATIONS:
Benicar for hypertension, Plaquenil for rheumatoid arthritis, and Celebrex for osteoarthritis. The patient is on no opioids and desires not to be at this time.

SOCIAL HISTORY:
She does not smoke. She does not drink alcohol and uses no recreational drugs or having issues with addiction. She is unemployed since October 2013 and she used to work in the area of producing seminars. She is on disability because of her rheumatoid arthritis. The patient is married. She has one child and she has a high school education.

ASSESSMENT:
1. This patient has combination of rheumatoid arthritis and osteoarthritis.
2. She has evidence of greater occipital neuralgia.
3. She has possible radiculopathy of her upper and lower extremities.
4. She has idiopathic thrombocytopenia purpura.
5. Hypertension.

RECOMMENDATIONS:
1. I spent a great length of time discussing comprehensive treatment plan with this patient who seems to understand. Our plan is
2. To get an MRI of her cervical spine without contrast and nerve conduction study and electromyelogram of her bilateral upper extremities to locate where her pain may be coming from in her upper extremity. I am going to start treatment plan of intensive chiropractic and physical therapy too.
3. To increase circulation of the nerves and overall well-being and see her back in the clinic after these studies are drawn to discuss the treatment plan. The treatment plan could include bilateral greater occipital nerve blocks in the office. She currently has MRI study and she may or may not need facet blocks done through surgery center.
4. We discussed some possibility in the future of Botox treatment for her bilateral lower extremity allodynia related to neuropathy.
5. We discussed the possibility of acupuncture and nutrition counseling in the future as well. The patient is also going to discuss with her hematologist the fact that her platelet count is 68,000 and whether or not she is a candidate for greater occipital nerve block and lesser occipital nerve block without further transfusion. The patient is going to bring all of her lab work and radiographic studies including the results with her on her visit with me in two to three weeks.

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