Arthropathy Case Summary
DOI: 4/19/2010. The patient is a 62-year old male truck driver who sustained a work-related injury to his neck and bilateral shoulders when he slipped and fell from his truck. The patient was subsequently diagnosed with cervical radiculopathy, lumbar radiculopathy, and neck, mid back and low back pain. MRI of the lumbar spine dated 3/9/16 (no official result) revealed multilevel degenerative disc disease and facet arthropathy with levoscoliosis and retrolisthesis, canal stenosis, and neural foraminal narrowing. MRI of the cervical spine dated 3/9/16 (no official result) revealed multilevel degenerative disc disease and facet arthropathy with levoscoliosis and retrolisthesis, and neural foraminal narrowing. As per medical report dated 3/31/16, patient presents with neck and low back pain. He states that his symptoms have remained persistent and unchanged. He recently started chiropractic therapy and has completed 2 sessions. He states that it has provided him moderate relief.
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Patient also had previous injection in the left shoulder and says that it has helped to alleviate his pain in the shoulder as well as in the neck. Patient last worked on 4/19/2010. It was noted that patient has had greater than 20 sessions of physical therapy since 1/2015 and had provided moderate relief. Current medications include Prilosec 20mg and Cymbalta Delayed Release 30mg. These medications provide pain relief which decrease a pain scale of 5/10 to 4/10. He says that the medication help with walking by at least 10 minutes. He reports a burning pain in the stomach next to his ribs. Per treatment plan, patient will continue the chiropractic care. There is ongoing request for orthopedic follow ups. Patient will continue Cymbalta 30 mg for chronic pain and Prilosec 20 mg. It was also noted that patient had recurrent gastritis related to NSAID
Patient also had previous injection in the left shoulder and says that it has helped to alleviate his pain in the shoulder as well as in the neck. Patient last worked on 4/19/2010. It was noted that patient has had greater than 20 sessions of physical therapy since 1/2015 and had provided moderate relief. Current medications include Prilosec 20mg and Cymbalta Delayed Release 30mg. These medications provide pain relief which decrease a pain scale of 5/10 to 4/10. He says that the medication help with walking by at least 10 minutes. He reports a burning pain in the stomach next to his ribs. Per treatment plan, patient will continue the chiropractic care. There is ongoing request for orthopedic follow ups. Patient will continue Cymbalta 30 mg for chronic pain and Prilosec 20 mg. It was also noted that patient had recurrent gastritis related to NSAID