HISTORY OF PRESENT ILLNESS:
The patient returns today for reevaluation. He reports continued pain to his neck and upper back, but now also reports severe low back pain especially on his right side. He reports that it feels like “someone is sticking a knife in me.” He has had MRI scans performed of his cervical and lumbar spine. MRI of the cervical spine revealed a herniated disc at C7-T1 as well as other bulging discs. MRI of the lumbar spine revealed a herniated disc at L2-L3 as well as multiple bulging discs. There is also found an abnormal area in the kidney, which is felt most likely be a cyst. The patient informed met that he has already returned for ultrasound of the cyst and will continue to follow up with the physician who ordered this.
General: Alert and oriented. HEENT: Normocephalic. Chest: Normal respiratory effort with good chest wall excursion. Abdomen: Soft and nontender. Extremities: No clubbing, cyanosis, or edema. Neuromuscular examination: Sensation, reflexes, and motor are intact and symmetrical to bilateral upper and lower extremities. Range of motion is significantly reduced to the cervical and thoracolumbar spine. There is pain which is greater with cervical extension and greater with lumbar flexion. Spasm is noted to bilateral cervical, thoracic, and lumbar paraspinal musculature. Trigger points are noted to bilateral cervicothoracic and lumbar paraspinal musculature as well as bilateral upper trapezius muscles and bilateral gluteal musculature.
- Posttraumatic cervical sprain/strain.
- Posttraumatic thoracic sprain/strain.
- Posttraumatic lumbar sprain/strain.
The patient and I did have nice talk once again today. He is receiving medications from Dr. Santiago and will continue to receive his pain medications from Dr. Santiago at this time. We have asked for authorization to perform trigger point injections as I do think that will be great helpful for the patient’s severe pain. We are awaiting authorization and if and when we receive authorization, we will proceed with this treatment. In the meantime, the patient will continue with therapy and continue to follow up with his chiropractic physician in addition to Dr. Santiago and myself. He will call with me with any questions or concerns prior to next visit.