Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Arm Pain - Neuro Consult
Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS:
The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.
He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.PAST MEDICAL HISTORY:
He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia.CURRENT MEDICATIONS:
He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral. He also uses Lidoderm patches and multiple eye drops and creams.ALLERGIES:
He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.FAMILY HISTORY:
His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders.SOCIAL HISTORY:
He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago.REVIEW OF SYSTEMS:
He has intermittent chest discomfort. He has chronic tinnitus. He has urinary dribbling. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.PHYSICAL EXAMINATION:
Vital Signs: HR 72. RR 16.
General Appearance: Patient is well appearing, in no acute distress.
Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.
Chest: The lungs are clear to auscultation bilaterally.
Skin: There are no rashes or lesions.NEUROLOGICAL EXAMINATION:
Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact.
Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.
Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.
Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent.
Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.
Deep Tendon Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk.
Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal.RADIOLOGIC DATA:
MRI of the cervical spine, 05/19/08: I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.IMPRESSION:
The patient is a 58-year-old gentleman with one-year history of right arm pain. He also has a longstanding history of neck pain. His neurological examination is normal. He has an MRI that shows some degenerative changes. I do believe that his symptoms are probably referable to his neck. However, I do not think that they are severe enough for him to undergo surgery at this point in time. Perhaps another course of physical therapy may be helpful for him. I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal. We could still try to treat him with neuropathic pain medications.RECOMMENDATIONS:
1. I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.
2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with him.
3. We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations.
consult - history and phy., arm pain, deep tendon reflexes, arm, mri, spine, neurological, nerves, reflexes, hand, sensation, fingers, neck,
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