Age: 64.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Fall, Injection site pain, Intervertebral disc degeneration, Intervertebral disc displacement, Intervertebral disc protrusion
Clinical narrative: 6/12/2021 Slip and short fall on a hill, landing on right elbow  6/14/2021 Stabbing pain starts between shoulder blades and begins to radiate down right arm  6/15/2021 Visit with the Doctor; Mild pain to palpation right para thoracic spine, no rash, no swelling or bruising, good pulses both arms 1. Acute bilateral thoracic back pain - atypical presentaion with lightheaded sp get imaging to look for trunk cause 2. Cervical radiculopathy - get xaru here as well due to radiation done right arm and try medrol pack to start 3. Lightheaded - get clot, cardiac and updated renal test in case need CT imaging later of thorax ? Ordered x-ray of neck ? Ordered Methylprednisolone (didn't stop naproxen or hydrochlorothiazide)  6/21/2021 Visit with Doctor ? Trigger point injections ? Ordered PT evaluation  6/25/2021 ER visit  ? Ruled out heart or thyroid problems but didn?t look at the spine ? Commented that thoracic spine should be looked at ? Prescribed muscle relaxers  6/27/2021 Right hand weakening  6/28/2021 Visit with Doctor Neurologic: 4/5 R biceps Sensory: decreased to LT in R biceps and middle/ring fingers Reflexes: 1+ R, 2+ L Spine: pain with R lateral cervical rotation  pos R spurlings ? Ordered MRI and steroid shot ? Prescribed another round of methylprednisolone but stopped naproxen and hydrochlorothiazide  6/29/2021  PT  7/8/2021 Steroid shot at Pain Management  Diagnosis:  ? Displacement of cervical intervertebral disc without myelopathy  ? DDD (degenerative disc disease), cervical  ? Cervical spondylosis  ? Foraminal stenosis of cervical region  ? Essential hypertension  7/12/2021 PT   7/13/2021 Visit Doctor ? Ordered second shot and suggested seeing a surgeon ? MRI C spine 7.5.2021: C6-7 disc bulge and facet arthritis with severe L and mild R NF stenosis  7/22/2021 Second steroid shot  ? This patient presents having 80% improvement for a few days however by day 5 he actually had worsening pain.  The pain now is worse than baseline.  It is in the scapular area radiating to the right shoulder and into the right arm to the 5th digit.  He has some right-sided foraminal stenosis that is more mild at C4-5 and C6-7.  We will try splitting the difference and injecting at C5-6 to cover both of these areas to see if this gives him better and longer lasting relief.  We will also change to Kenalog to see if that is better for him  7/27/2021 Ordered EMG   8/10/2021 Ordered MRI and PT  8/12/2021 PT   8/16/2021 PT   8/20/2021 PT   8/24/2021 Visit with Doctor regarding possible infraspinatus tear ? x-rays taken showed no issue ? Range of motion was fine with no pain ? Brachial plexus stretch injury may take a long time for the nerves to heal ? Ordered hand occupational therapy  8/24/2021 agreed with Doctor  9/1/2021 PT. PTA, were very concerned about the progressing atrophy of right hand, arm and now shoulder. Suggested a second opinion and the possibility of Parsonage Turner Syndrome.  9/3/2021 Visit with Neurosurgery ? He will have cervical flex ext and return to be evaluated next week.  9/3/2021 PT   9/7/2021 Visit with Neurosurgery ? Review of cervical spine MRI from 7/6/21 demonstrates C7-T1 foraminal disc herniation pushing on the exiting C8 nerve root.   ? The patient is presenting with a distribution of symptoms that have changed in distribution and severity over the past week, so I would like to obtain a repeat cervical spine MRI to assess for new changes.  ? The patient may follow-up after imaging has been obtained. At that time, we can consider surgical intervention including possible right-sided C7-T1 minimally invasive foraminotomy and discectomy.  9/20/2021 Visit with the Doctor ? As the patient's symptoms do not align with a distinct dermatomal distribution with concordant findings on MRI, no neurosurgical intervention is recommended at this time. I advised him to follow up for possible intervention upon completion of PT, should his symptoms persist.  ? We will continue to follow the patient's progress.    9/23/2021 PT   9/27/2021 Visit with Orthopedics  9/30/2021 PT  10/1/2021 Received flu shot  10/12/2021 Visit with Doctor MRI showed full thickness tear of the common extensor tendon from the lateral humeral epicondyle. Nearly the entire common extensor origin is retracted by approximately 1.8 cm. A few of the posterior fibers may remain attached. There is also mile common flexor origin tendinopathy with a minimal area of low-grade partial thickness tearing. Small elbow effusion is noted.  10/18/2021 Visit with Neurology