Pain to her neck, upper back, low back

HISTORY OF PRESENT ILLNESS:

The patient returns today for reevaluation. She reports continued pain to her neck, upper back, low back as well as left wrist. She reports some improvement to all areas but does have continued pain. She denies any new complaints.

PHYSICAL EXAMINATION:

General: Alert and oriented. HEENT: Normocephalic. Chest: Normal respiratory effort with good chest wall excursion. Extremities: No clubbing, cyanosis, or edema. Left wrist is in a brace. Neuromuscular examination: Range of motion is reduced to the cervical and thoracolumbar spine. Spasm and rigidity is noted to the cervical, thoracic, and lumbar paraspinal musculature. Trigger points are noted to multiple areas with the most significant being to bilateral cervical paraspinal musculature, bilateral upper trapezius muscles, and bilateral scapulothoracic regions.

IMPRESSION:

  1. Posttraumatic cervical sprain/strain.
  2. Cervical radiculopathy – improved.
  3. Posttraumatic thoracic sprain/strain.
  4. Posttraumatic lumbar sprain/strain.
  5. Lumbar herniated disc.
  6. Posttraumatic left carpal tunnel syndrome.

PLAN:

The patient and I did have a nice talk today. We did get authorization for trigger point injections and we did readdress the risks and benefits of this procedure. The patient decided to proceed with the procedure. A solution of lidocaine 1% 2 cc, Marcaine 0.25% 0.5 cc, and betamethasone 30 mg per 5 mL 1 cc was used. Injections were done to bilateral upper trapezius muscles, bilateral cervical paraspinal muscles, and bilateral scapulothoracic regions. A total of six injections were performed. The patient tolerated the procedure well. There were no complications. The patient will continue with physical therapy as well as icing and home exercise. She will continue to follow up with the other physicians that are seeing her. I will see her in follow-up in two weeks’ time. We may do more trigger point injections at that time. She will call me with any questions or concerns prior to this.

 

Advertisements

Leave a Reply