DOI: 8/12/2009. Patient is a 48-year-old female account executive who alleges neck injury aggravated by work. As per OMNI notes, the patient is status post cervical spine surgery at C5-7 on 8/8/2011.
Based on the progress report dated 09/14/16, the patient presents for neck pain radiating from neck down and right shoulder pain.
Patient rates her pain with medications as 4/10 and without medications as 7/10.
Quality of sleep is fair. Patient is active for limited hours and takes part in limited social activities. The patient is taking her medications as prescribed. She states that medications are working well. No side effects are reported. Her activity level has decreased.
Patient states cervical pain has remained relatively the same since …show more content…
Tenderness is noted at the paracervical muscles, rhomboids and trapezius, as well as cervical paraspinal muscles. Spurling's maneuver causes pain in the muscles of the neck. There is tenderness to bilateral facets with palpation. There is pain with facet loading bilaterally.
Patient appears to be depressed and in mild-to-moderate pain.
On examination of the right shoulder, movements are restricted with flexion to 145 degrees, extension to 50 degrees, abduction to 80 degrees, internal rotation behind body to 40 degrees and external rotation to 40 degrees. Hawkins test, Neer’s test, Shoulder crossover test, Empty Can’s test and Speed’s test are positive.
The right hand is in rigid splint, 3rd and 4th finger fixed.
Motor testing is limited by pain right upper extremity. Motor strength is 4+/5 on right finger flexor's, 4/5 on right grip, finger extensor's, wrist flexor's and wrist extensor's, and 4-/5 to right elbow flexor's, elbow extensor's and shoulder abduction.
Sensation to light touch is decreased over the C5 and C6 upper extremity dermatomes on the right side.
IW was diagnosed with other spondylosis with myelopathy of the cervical region, postlaminectomy syndrome and cervical …show more content…
Patient has failed gabapentin, nortriptyline and Lyrica. Patient reports greater than 50% relief and is able to sleep 7 hours compare to 3-4 hours without Cymbalta. Nucynta intermediate release (IR) is for breakthrough pain control and Nucynta extended release (ER) for long acting pain control. Nucynta has been very effective for her pain. Patient notes that the medication is helpful to get through the day. Patient notes that with medications, she can get groceries and run errands and reports an increase of activity. She states that without the medications she is less active. It was further noted that these medications are intended for use together (one is short acting and one is long
Based on the progress report dated 09/14/16, the patient presents for neck pain radiating from neck down and right shoulder pain.
Patient rates her pain with medications as 4/10 and without medications as 7/10.
Quality of sleep is fair. Patient is active for limited hours and takes part in limited social activities. The patient is taking her medications as prescribed. She states that medications are working well. No side effects are reported. Her activity level has decreased.
Patient states cervical pain has remained relatively the same since …show more content…
Tenderness is noted at the paracervical muscles, rhomboids and trapezius, as well as cervical paraspinal muscles. Spurling's maneuver causes pain in the muscles of the neck. There is tenderness to bilateral facets with palpation. There is pain with facet loading bilaterally.
Patient appears to be depressed and in mild-to-moderate pain.
On examination of the right shoulder, movements are restricted with flexion to 145 degrees, extension to 50 degrees, abduction to 80 degrees, internal rotation behind body to 40 degrees and external rotation to 40 degrees. Hawkins test, Neer’s test, Shoulder crossover test, Empty Can’s test and Speed’s test are positive.
The right hand is in rigid splint, 3rd and 4th finger fixed.
Motor testing is limited by pain right upper extremity. Motor strength is 4+/5 on right finger flexor's, 4/5 on right grip, finger extensor's, wrist flexor's and wrist extensor's, and 4-/5 to right elbow flexor's, elbow extensor's and shoulder abduction.
Sensation to light touch is decreased over the C5 and C6 upper extremity dermatomes on the right side.
IW was diagnosed with other spondylosis with myelopathy of the cervical region, postlaminectomy syndrome and cervical …show more content…
Patient has failed gabapentin, nortriptyline and Lyrica. Patient reports greater than 50% relief and is able to sleep 7 hours compare to 3-4 hours without Cymbalta. Nucynta intermediate release (IR) is for breakthrough pain control and Nucynta extended release (ER) for long acting pain control. Nucynta has been very effective for her pain. Patient notes that the medication is helpful to get through the day. Patient notes that with medications, she can get groceries and run errands and reports an increase of activity. She states that without the medications she is less active. It was further noted that these medications are intended for use together (one is short acting and one is long