The patient is a 55-year-old female, who has been under the care of Dr. for neck pain, right shoulder pain and upper extremity pain. She reports that her pain has been present for approximately one and half years and has been getting progressively worse. She works as a letter carrier and feels that this may be exacerbating her symptoms. She reports neck pain with pain to her left shoulder. She does report radiation of pain down the left upper extremity as well as pins and needle sensations to both hands and down both arms. She also reports weakness to the left upper extremity at times. She has had an MRI scan of the cervical spine. MRI scan did reveal herniated discs at C4-C5 and C6-C7. An MRI scan has been ordered of the left shoulder although has not yet been done. She also has an electrodiagnostic testing, which revealed a right C7 radiculopathy as well as a moderate right median nerve neuropathy at the wrist. It also revealed a sensory peripheral neuropathy predominantly affecting bilateral extremities of the axonal and demyelinating type. She does have some low back symptoms as well on the electrodiagnostic testing elsewhere with an L4 and L5 radiculopathy. The patient denies any prior treatment for these symptoms. She has not taken any medications specifically for this pain with exception of over-the-counter Tylenol and Motrin at times. She has begun physical therapy here at this office.
1. Cervical herniated disc.
2. Cervical radiculopathy.
4. Rotator cuff syndrome.
5. Carpal tunnel syndrome.
7. Myofascial pain secondary to all the above.
The patient and I did have nice talk today regarding her pain and overall plan of care. We discussed the number of treatment options and Dr. had recommended trigger point injections for her. We discussed the risks and benefits of the procedure verbally and she did sign a written informed consent form. The consent form was more of dry needling. I did specifically address verbal trigger point injections using the medications we decided to use. A solution of lidocaine 1% 4 cc, betamethasone 30 mg per 5 mL 1 cc was used. Injections were done to the left upper trapezius, in lower cervical paraspinal musculature, left scapulothoracic region and left deltoid were done. A 27-gauge, 1.5-inch needle was used. The patient tolerated the procedure well. There were no complications. We also specifically discussed that as a diabetic, she needs to understand that this injection could increase her blood sugar and she will monitor for any side effects and call her primary care physician if she has any issues. The patient and I also discussed medications. She is only taking over-the-counter medications at this time for this pain. I did give her a prescription for naproxen 500 mg one tablet twice daily for anti-inflammatory effects. We did discuss GI precautions. In addition, she was given a prescription for cyclobenzaprine 10 mg one tablet before bed as needed to help with her spasm. We discussed that she will not drive or operate any machinery while taking this medication.
The patient will continue with physical therapy. She will use ice and we did discuss gentle home exercise. We also discussed that she will definitely get the MRI scan performed of her left shoulder as I do believe that there is significant shoulder Pathology contributing to her symptoms as well. We further discussed that if these trigger point injections do not provide relief, she may consider interventional procedures such as a cervical epidural steroid injection with Dr.. She will have a follow up with me in two weeks’ time. She will call me if there are any questions or concerns prior to this.