[doctor] dictating on donald clark . date of birth , 03/04/1937 . chief complaint is left arm pain . hello , how are you ?
[patient] good morning .
[doctor] it's nice to meet you . i'm dr. miller .
[patient] it's nice to meet you as well .
[doctor] so , i hear you are having pain this arm . is that correct ?
[patient] that's correct .
[doctor] okay . and it seems like it's worse at night ?
[patient] well , right now the hand is .
[doctor] mm-hmm .
[patient] and the thing started about two weeks ago . i woke up about two o'clock in the morning and it was just hurting something awful .
[doctor] uh- .
[patient] and then i laid some ice on it and it finally did ease up .
[doctor] okay , that's good .
[patient] so i got up , i sat on the side of the bed and held my arm down , thinking it would , like , help the circulation , but it did n't .
[doctor] okay , i see .
[patient] and so , after a while , when it eased off , maybe about four , five am , i laid back down and it did n't start up again .
[doctor] mm-hmm , okay .
[patient] um . i went back to sleep but for several nights this happened , like , over and over . so , i finally went to see the doctor , and i do n't really recall her name .
[doctor] okay . yeah , i think i know who you're talking about , though .
[patient] um , she's the one who sent me to you , so , i , i would , i would think so . but when i went to her after the third time it happened and she checked me out , she said it was most likely coming from a pinched nerve .
[doctor] probably . uh , do you notice that moving your neck or turning your head seems to bother your arm ?
[patient] uh , no .
[doctor] okay . is moving your shoulder uncomfortable at all ?
[patient] no .
[doctor] and do you notice it at other times besides during the night ?
[patient] um , some days . if it bothers me at night , then the day following , it usually will bother me some .
[doctor] okay . and do you just notice it in the hand , or does it seem to be going down the whole arm ?
[patient] well , it starts there and goes all the way down the arm .
[doctor] okay . have you noticed any weakness in your hand at all ?
[patient] uh , yes .
[doctor] okay . like , in terms of gripping things ?
[patient] yeah .
[doctor] okay .
[patient] uh , this finger , i hurt it some time ago as well .
[doctor] really ?
[patient] yeah . it does n't work properly . or , it works very rarely .
[doctor] gotcha . and did i hear that she gave you some prednisone and some oral steroids , or ?
[patient] uh , well , she gave me some numbing medicine . it helped a little bit . the other two were a neck pill and gabapentin . uh , you should have my full list in your notes , though . since then it has n't really bothered me at night . also , just so you know , i am a va and i'm one percent disabled from this leg , um , issues from my knees down to my feet .
[doctor] okay . is it neuropathy ?
[patient] uh , yep .
[doctor] gotcha . that is good to know . all right , well , let's go ahead and take a look .
[patient] okay .
[doctor] all right . so , to start , i'm gon na have you do something for me . uh , just go ahead and tilt your chin as far as you can down to your chest . okay , good . and now , go the other way , tilting your chin up as far as you can . now , does that seem to bother you at all ? okay . and now , come back to normal , just look and turn your head as far as you can that way . great . and now , as far as you can towards that wall . uh , does that seem to bother you at all ?
[patient] no . well , actually , i do feel a little strain .
[doctor] okay . so , you feel it in the neck a little bit ?
[patient] yeah , just a little strain .
[doctor] okay . uh , now squeeze my fingers as hard as you can with both hands . great . now , hold your arms like this .
[patient] okay .
[doctor] and i'm going to try to strain your arms and try to keep them as stiff as you can . do n't let me strain it . okay , good . good . now , when i , i'm just touching your hands like this . does it seem to feel about the same in both hands ?
[patient] uh , yes .
[doctor] okay . all right . so , i do agree with betty . uh , more than likely , this seems like it would be coming from your neck . that's the most common reason that causes what , what you're experiencing . and i looked at an x-ray of your neck , and you do seem to have a lot of arthritis there , and there does seem to be potential for a disc to be pushing on a nerve . and now , what i do n't have is an mri , which would show me , uh , kind of exactly where the nerve roots are getting pinched off .
[patient] i see .
[doctor] so , gabapentin can help a little bit with the nerve pain , and what i would like to do is potentially set you up for an epidural . and what that is is it , it's a focused anti-inflammatory medicine , excuse me , that works behind the nerve roops that , nerve roots that we are thinking might be getting squished off . it can often help alleviate your symptoms , and i do need to get an mri of your neck . um , i know we have had one of your lower back , but i need one of your neck to see exactly where the roots are getting pinched off . so , what i can do is tentatively set you up for an epidural , but before you do that , we do need to get that mri so i can see right where i need to put the medicine for your epidural . uh , what do you think of that ?
[patient] i think that sounds good to me .
[doctor] okay , good . and just to confirm , do you take any blood thinners ? i do n't think i saw any on your medicine list .
[patient] uh , no , i do n't .
[doctor] okay , good . and what i would have you do is continue with the gabapentin . um , are you taking 300 or 100 ?
[patient] um , not sure . my lady friend helps me handle this stuff .
[doctor] okay .
[patient] i am taking eliquis , though .
[doctor] okay . um , so whatever you are doing you can just keep doing it , and i'm going to set you up for the epidural and imaging study , um , just so i know right where to put the medicine . and i will follow up with you after s- um , that's in . we can do the shot , just to make sure your arm is feeling better . sound good ?
[patient] sounds good . for the last couple of nights , though , my neck has not been bothering me .
[doctor] okay . s- um , so , presumably what's happening , then , is when you're sleeping your neck is kind of gets off-tilt , uh , kilter , and it compresses the nerve roots there . now , if you think you're doing fine , we could hold off , but at the very la- least , i'd like to update that mri of yours and see what's going on , because probably this is something that will likely flare up again .
[patient] yeah , it , it has been for the last week , so , i understand .
[doctor] okay . all right . well , do you want to do that work-up and do the epidural , or do you think you're doing fine and you want to wait ?
[patient] well , my hand is still bothering me .
[doctor] okay . so , you're saying your neck is not bothering you but the hand is . okay . so then , let's just stick with the plan . mri of the neck , so we can see where the nerve roots may be compressed , that's giving your hand the issue . and then , we're going to set you up with the epidural .
[patient] okay . sounds good .
[doctor] all right . so , keep going with the gabapentin . i will order the imaging of your neck , and the shot will hopefully help some with those symptoms in your hand , and then we'll follow up afterwards .
[patient] all right . is the mri today ?
[doctor] um , you probably ca n't do it today , but let me talk with roy and see how soon we can get it done . just give me a quick minute , and then roy will come in and get things scheduled as soon as we can .
[patient] all right .
[doctor] all right . well , it was nice meeting you , my friend .
[patient] you as well . thank you .
[doctor] physical exam , elderly white gentleman presents in a wheelchair . no apparent distress . per the template , down through neuro- neurologic . one plus bilateral biceps . triceps brachioradialis . reflexes bilateral all negative . follow up and take out the lower extremities . gait not assessed today . strength and sensation is per the template . uh , upper and lower extremities . musculoskeletal , he is non-tender over his cervical spine . he does have mildly restricted cervical exte- extension . right and left lateral rotation which is symmetric , which gives him mild lateral neck pain but no radi- radicular pain . spurling's maneuver is benign .
[doctor] paragraph , diagnostics . cervical x-ray 6421 . cervical x-ray reveals significant disc degeneration at c56 , and to a lower extent c45 and c34 . significant lower lumbar facet arthropathy c67 and c7-t1 is difficult to visualize in the current x-rays .
[doctor] paragraph , impression . number one , left upper extremity neuropathy suspicious for cervical radicularopathy . possible contribution of peripheral neuropathy . number two , neck pain in the setting of arthritis disc degeneration .
[doctor] paragraph , plan . i suspect that this is a flare of cervical radicularopathy . i'm going to set him up for a cervical mri , and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners .

Medical orders:
description: mri mri of your neck neck
order_type: imaging
reason: here does seem to be potential for a disc to be pushing on a nerve so i can see right where i need to put the medicine for your epidural
description: follow up
order_type: followup