Download Page 1 of 4 Patient Name : DODSON, PAULETTE Date of Birth : 09

River North Pain Management Consultants
Axel Vargas, M.D.,
Regional Anesthesiology and Interventional Pain Management.
One East Erie Suite # 300
Chicago, Illinois, 60611
Patient Name
:
DODSON, PAULETTE
Date of Birth
:
09/23/63
MR#
:
083-56-8042
Date of service :
Phone: (312) 951-6471
Fax: (312) 649-5747
E-mail: [email protected]
www.rivernorthpmc.com
07/02/08
HISTORY OF PRESENT ILLNESS: Mrs. Dodson comes referred by Dr. Adam Bennett
for consultation. Mrs. Dodson is a very pleasant 44-year-old corporate attorney from
Chicago, Illinois with a 1½ -months history of progressively worsening “severe posterior
left neck pain” with associated left scapular “stabbing pain” and radiation into her left
upper extremity via a postero-lateral route into her arm, forearm and into her left hand.
Mrs. Dodson is a poor historian; nevertheless she informs me that approximately 1½ months ago, she woke up with left posterior cervical stiffness which progressively
worsened throughout the day and became associated with intense stabbing pain to her
left scapulae and radiation unto her left upper extremity via a postero-lateral route. The
pain was so intense that she called Dr. Adam Bennett whom readily prescribed a course
of NSAID’s, oral opiate analgesics, i.e., Hydrocodone, a course of oral steroids, i.e.,
Medrol Pack and recommended prompt physical therapy.. Her pain continued despite
these therapeutic maneuvers. She then saw Dr. Bennett whom obtained
Electromyography and MRI studies of her cervical spine. Her overall pain and radicular
symptoms have continued to progressively worse as it increased both in frequency and
intensity and has somewhat hindered some of her daily activities.
Currently, her pain is described as a constant, “sharp, stabbing, at times electrical-like
shooting pain” which arises at the level of her distal left posterior cervical region and
radiates caudally into her left scapulae, left axillary region, as well as into her left upper
extremity via a postero-lateral route into her left arm, left forearm and into her left hand.
She acknowledges paresthesia manifested mostly as a “tingling sensation” throughout
the dorsal and lateral aspect of her left C6-C7 dermatome.
She denies allodynia, dysesthesia, hyperpathia, hyperalgesia, or any temperature
discrepancies between both upper and lower extremities. She denies as well fever,
chills, night sweats, nuchal rigidity, dysphagia, diplopia, occipital headaches, jaw or
tongue paresthesia, gait or balance disturbances, saddle anesthesia, neurological or
vascular claudication, focalized weakness, contralateral pain, foot drop, or any bowel,
bladder or sexual dysfunction of radicular origin.
She, as above, acknowledges frank paresthesia manifested mostly as a “pins and
needles” throughout the left C6-C7 dermatome.
She rates her neck pain as a 9-10/10 on the numeric pain scale (NPS) at its worst, and
as a 5-6/10 on the same scale at its best. Her level of pain does increase upon specific
triggering maneuvers such as flexion of her cervical spine, as well as ipsilateral flexion.
Her sleep pattern has been affected as well for she is not able to either initiated nor
maintain restorative sleep as her pain interferes with the ability to lay on her left side.
Her overall level of activity has been affected as well due to her current symptoms.
One East Erie Street, Suite # 300
Chicago, IL. 60611
Phone: (312) 951-6471 Fax:(312) 649-5747
E-mail: [email protected]
www.rivernorthpmc.com
Page 2 of 4
PAST MEDICAL HISTORY: Mrs. Dodson acknowledges history of
hypercholesterolemia. She denies hypertension, coronary artery disease (CAD), or
diabetes.
PAST SURGICAL HISTORY: S/P Cervical biopsy for dysplasia
MEDICATIONS: Hydrocodone,Voltaren; she also completed yesterday a course of oral
steroids, i.e., Medrol Pack.
ALLERGIES: Denies any allergies to any medications.
TOBACCO: The patient denies history of smoking.
ETOH: She drinks alcohol on a social basis. She denies history of alcohol substance
abuse
SOCIAL HISTORY: Mrs. Dodson is a corporate attorney; she is married and lives with
her husband and her 2-children.
FAMILY HISTORY: Non contributory
REVIEW OF SYSTEMS: All systems were reviewed and found to be within normal
limits, with the exception of history of present illness and previous surgical history.
PHYSICAL EXAMINATION: The patient appears to be in mild to moderate distress. She
ambulates into the examining room without any significant gait disturbance and climbs
onto the examining table at ease.
VITAL SIGNS: Blood pressure 110/82, respiratory rate 12, heart rate 62, and pulse
oximetry on room air 100%.
HEAD: Normocephalic, atraumatic.
EYES: PEERLA/EOMI’S intact.
FACE: Normal facial bone architecture. There is no evidence of droops, or
asymmetries.
NECK: Reveals no JVD, no bruit, no lymphadenopathies. Neck examination also
reveals a decreased global excursion of the cervical spine with diminished forward
flexion (30˚-40˚), decreased ipsilateral (left) lateral flexion (20˚-25˚), and decreased
cervical spinal extension (-45˚). Rotational exertion of the cervical spine does not yield
any facet-like pain when carried bilaterally beyond a 70˚-80˚ degree angle.
Inspection of the cervical spine reveals no deformity, no gibbus, nor recent or remote
trauma. Palpation throughout the cervical as well as proximal thoracic spinal processes
reveals no step-downs and there is no tenderness elicited. Deep palpation of the
paraspinous musculature at the level of the cervical and thoracic paraspinous region
bilaterally reveals no taut bands and there is no tenderness elicited. Vertex compression
test (Spurling test) and L’Hermitte sign were found to be positive on the left.
Costoclavicular maneuver, Wright and Adson’s test were negative for thoracic outlet
syndrome.
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UPPER EXTREMITY: Reveals normal motor strength (5/5) throughout the different
muscle groups, i.e. deltoid, biceps, triceps, pronator teres, brachioradialis, wrist
dorsiflexors, wrist dorsiextensors and interossei muscles bilaterally. Bilateral
Supraspinatus, infraspinatus, teres minor, and subscapularis muscle apparatus appears
intact as well. Deep tendon reflexes appear decreased symmetrically (1+/2+),
throughout her left upper extremity. Neurosensory examination when tested via pinprick
response reveals mildly to moderately decreased response throughout the left C5-C6
and C6-C7 dermatome. There is no obvious evidence of muscular atrophy or throphic
skin changes throughout the both upper extremities. There is no evidence of thenar or
hypothenar atrophy either. There are no discrepancies between the temperatures on
both upper extremities when tested via temperature strip. There is no evidence of
hyperalgesia, hyperpathia, or allodynia either. Vascular examination reveals normal
pulses throughout. There is adequate capillary refill (> 2 seconds). A two point
discrimination test appears intact.
SHOULDER EXAM: reveals no sub-acromial crepitance or pain. The Neer Test
(Shoulder Internal Rotation) as well as Hawkins Test (Internal and external rotation)
were found negative. There is no pain on externally rotating either arm noir on passively
elevating them to 180 degrees. There is no Supraspinatus weakness or external rotation
weakness. Global upper extremity range of motion appears to be intact as well.
LUNGS: Clear to auscultation and percussion.
HEART: S1 and S2 within normal limits.
ABDOMEN: Non-tender, non-distended.
BACK: On inspection there is no evidence of significant deformity, scoliosis, kyphosis,
lordosis or gibbus. Palpation throughout the distal thoracic and lumbosacral spine
processes reveals no step-downs and there is no tenderness elicited. Global excursion
of the lumbosacral is within normalcy. Rotational exertion of the lumbo-sacral spine
when carried beyond 35˚ angle, i.e. facet loading maneuver does not yield any facet-like
pain response. The patient is able to toe walk and heel walk without any difficulty, and is
able to squat upon request without any exacerbation of the pain.
Sciatic stretch tests, i.e. Straight leg (Lesegue sign), Braggard test; and Bechterew test
do not elicit any irritation response. SLE appears to be intact bilaterally (90˚).
LOWER EXTREMITY: Reveals normal motor strength (5/5) throughout the different
muscle groups bilaterally. The patient is able to adduct (30˚) and abduct (30˚-50˚) both
hips as well. Deep tendon reflexes are within normalcy as well (2+/2+) bilaterally.
Neurosensory examination when tested via pinprick response reveals no significant
subjective decrease response throughout.
IMAGING STUDIES: MRI studies of the cervical spine obtained on 06/17/08 reveals:
multilevel degenerative disk disease more pronounced at the level of C5-C6 and C6-C7
levels.
IMPRESSION
1.
2.
3.
4.
Multilevel cervical spondylosis.
Multilevel disk disease of the cervical spine at the C5-C6 and C6-C7levels.
neuroforaminal stenosis.
Left-sided cervical radiculopathy (C6-C7).
PLAN: Mrs. Dodson's history, clinical presentation, physical and radiological findings,
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are suggestive of a multilevel degenerative disk disease moer pronounced at the C5-C6
and C6-C7 levels, resulting in a neuroforaminal stenosis with a consequent left sided
radiculopathy.
Due to the nature of her diffuse multilevel degenerative disc disease one could argue
that Mrs. Dodson would preferably benefit from an interlaminar approach rather than a
transforaminal approach for the spread of the anti-inflammatory drug, i.e. steroid, will be
greater with the former.
Under this light I will proceed with a series of cervical interlaminar fluoroscopy guided
epidural steroid injections, the first of which I will perform today.
Today I had a lengthy discussion with Mrs. Dodson in reference to the risk versus
benefits ratio, real expectations, and remote complications associated with this modality
of treatment. I utilized an anatomical model as well as computer generated graphics to
illustrate to the patient the technicalities involved in this procedure as well as the
potential complications associated with it and with the deliverance of steroids into the
central axis. I answered all her questions in layman’s terms. She understands all of the
above and duly consents for the procedure.
Additionally, she would indeed benefit from focused physical therapy, once her pain and
radicular symptoms subside, in order to further increase her clinical improvement.
Sincerely,
Axel Vargas, M.D.
AV/yn
CC: Adam Bennett M.D.,
Northwestern Orthopaedic Institute
680 North Lake Shore Drive, suite # 1028
Chicago, Illinois 60611
Chart