Doctor: Patient:
Aman Deep MD Jeffrey Cruz
Location: DOB:
Babylon
170 East Main Street Babylon, NY 11702
02-22-1956
Follow-Up Examination
DOS: 09-27-2021 Patient: Cruz Jeffrey
DOB: 02-22-1956
Mr Cruz was last evaluated on 08/30/2021. The patient explains that they have experienced good relief with prior trigger point injections. They are requesting today a lumbar trigger point injection to relieve their symptoms. Pt presents today after 1 month with return of his left hip pain. He states his pain starts in his buttock and wraps around the left hip and runs down the left leg to the knee. On a scale from 1-10, 10 being the worst, the patient rates their pain in the following manner. Neck pain is a 5. which is worse. Upper back pain is a 8. which is worse. Mid back is a 2. which is improved. Lower back is a 8.
which is the same. The lower back pain radiates down the left leg to the buttock. The left shoulder pain is a 7. which is worse.
The right shoulder pain is a 4. which is improved. Left knee pain is a 9. which is worse. Left hip is a 9. which is worse. They state that the pain is worse in the evening. The pain is exacerbated by general activity. They have tried treating the pain with chiropractic treatment and trigger point injections.
Past Medical History -Hypertension -Arthritis
Past Surgical History
Reconstructive surgery right foot due to fallen arch in 2000 ; gastric bypass in 2005.
Medications
Ibuprofen -Unnamed AntiHypertensive
Allergies -Penecillin
Family
Mother had diabetes Father had diabetes
Social
Drinks Socially
The patient smokes 4 cigarettes a week.
Occupation
The patient is working as a body shop owner.
Review of Systems
The patient denies fevers, chills, shortness of breath, chest pains, visual changes and bowel/bladder incontinence.
The patient states they have trouble sleeping at night because of the pain.
Physical Exam Height: 6` 4``
Patient: Cruz Jeffrey DOB: 02-22-1956 DOS: 09-27-2021 Location: 170 East Main Street Babylon NY 11702
Weight: 270 lbs Heart Rate: 82
Blood Pressure: 131 / 76
Gait: The patients gait is antalgic due to lower back pain and hip pain. Also having difficulty ambulating due to left knee pain.
Chest: CTA b/l, No W/R/R Heart: S1, S2
Abdomen: Soft, NT, +BS
Comprehensive Orthopedic Physical Exam
Cervical Spine
There is moderate tenderness to palpation throughout the cervical spine specifically from C4 through C7. The patient experiences pain when palpating the trapezius and para-cervical muscles on the left and right indicating myalgia. On the left there are moderate trigger points noted in the splenius capitus and trapezius muscles. On the Right there are moderate trigger points noted in the splenius capitus and trapezius muscles. There is pain noted with left and right rotation.
Cervical Tests
The foraminal compression test is negative. The shoulder depression test is negative. The Lâ ™Hermittes test for cervical myelopathy is negative.
Cervical Range Of Motion
Present Normal
Flexion 40 50
Extension 50 50
Left Rotation 70 85
Right Rotation 70 85
Left Flexion 45 45
Right Flexion 45 45
Cervical Neuromotor Exam Left
Present Right
Present Normal
C5 Biceps 5/5 5/5 5/5
Bicep Tendon Reflex +2 +2 +2
C6 Wrist Extensors 5/5 5/5 5/5
Brachioradialis Tendon
Reflex +2 +2 +2
C7 Triceps 5/5 5/5 5/5
Triceps Reflex +2 +2 +2
C8 Finger Flexors 5/5 5/5 5/5
T1 Finger Abduction 5/5 5/5 5/5
Thoracic Spine
There is moderate tenderness to palpation noted at thoracic levels T5 through T10. On the right there are trigger points noted to palpation to be moderately tender in the thoracic paraspinal region. On the left there are trigger points identified on palpation to be moderately tender in the thoracic paraspinal region.
LUMBOSACRAL SPINE
There is severe tenderness to palpitation noted at lumbosacral levels L2 through S1. On the left trigger points are noted upon palpation to be severely tender. On the right trigger points are noted upon palpation to be moderately tender. There is
Patient: Cruz Jeffrey DOB: 02-22-1956 DOS: 09-27-2021 Location: 170 East Main Street Babylon NY 11702
tenderness noted over the left sacroiliac joint. There is pain reported with restricted range of motion in left rotation, right rotation, flexion and extension.
LUMBOSACRAL TESTS
The straight leg test is positive on the left, eliciting lower back pain.
The sacroiliac compression test is positive on the left.
LUMBOSACRAL Range Of Motion
Present Normal
Flexion 65 90
Extension 10 25
Left Rotation 25 45
Right Rotation 30 45
Left Flexion 15 25
Right Flexion 15 25
Lumbosacral Neuromotor Exam
Left Present Right Present Normal
L1/L2 Hip Flexors 5/5 5/5 5/5
L3 Quadriceps 5/5 5/5 5/5
L4 Patellar Tendon Reflex +2 +2 +2
Dorsiflexion 5/5 5/5 5/5
L5 Hamstring Jerk +2 +2 +2
1st Toes Extensions 5/5 5/5 5/5
S1 Ankle Jerk +2 +2 +2
Plantar Flexion 5/5 5/5 5/5
Left shoulder
The left shoulder is noted to be tender to palpation at the gleno-humeral joint. Tenderness is noted along the superior border of the scapula. Evidence of impingement was shown after positive abduction test which was performed and was strongly positive. Weakness of the supraspinatus muscle was demonstrated by a positive empty can test which was mildly positive.
Sholder Range Of Motion
Left Present Normal
Foward Flexion 160 180
Extension 40 50
Abduction 110 130
Internal Rotation 75 90
External Rotation 75 90
Right shoulder
The right shoulder is noted to be tender to palpation at the gleno-humeral joint. Tenderness is noted along the medial border of the scapula. Evidence of impingement was shown after positive neers test which was performed and was mildly positive. Weakness of the supraspinatus muscle was demonstrated by a positive empty can test and resisted isometric abduction test which was mildly positive. Weakness of the infraspinatus muscle and teres minor was demonstrated by a positive isometric external rotation test which was mildly positive.
Sholder Range Of Motion
Right Present Normal
Foward Flexion 170 180
Patient: Cruz Jeffrey DOB: 02-22-1956 DOS: 09-27-2021 Location: 170 East Main Street Babylon NY 11702
Extension 40 50
Abduction 110 130
Internal Rotation 75 90
External Rotation 75 90
LEFT HIP
There is tenderness to palpation noted over the piriformis and gluteal muscles. The piriformis test is positive.
Hip Range Of Motion
Left Present Normal
Foward Flexion 105 120
Extension 15 30
Abduction 40 40
Abduction 25 25
Internal Rotation 20 35
External Rotation 25 45
LEFT KNEE
There is small effusion noted. There is medial joint line tenderness to palpation and pain noted with valgus stress, and pain noted with varus stress which is severe. There is infrapatellar tenderness to palpation.
KNEE Range Of Motion
Left Present Normal
Flexion 115 135
Extension 5 0
IMAGING STUDIES
XRAY Left Knee 9-26-18There are mild osteoarthritic degenerative changes. M17.12 bony distortion of the proximal tibial metaphysis with exostotic type changes. These changes could be posttraumatic or congenital. Correlation with history and full images of the tibia suggested.
MRI Left shoulder 12-12-18 - Very severe glenohumeral joint osteoarthritis, with trace joint effusion, and with an
osteocartilaginous body in the subscapularis synovial recess. Mild-to-moderate rotator cuff tendinosis, with a tiny linear intrasubstance tear at the insertion of the supraspinatus tendon. Mild long head biceps tendinosis. Mild AC joint osteoarthritis.
MRI Lumbar spine 12-12-18 - Spinal malalignment with multilevel degenerative disc disease including herniations and stenoses as above. OLD INS Empire Blue Cross Blue Shield UQVAN4530649
IMPRESSION/DIAGNOSIS:
CERVICAL
Cervical Sprain/Strain S13. 4XXA.
Cervical Myalgia M79. 18.
Cervical Trigger Points M54.12, M54.2, M79.12.
Cervicalgia M54. 2.
THORACIC
Thoracic Sprain S23. 3XXA.
Thoracic Myalgia M79. 18.
Thoracic Trigger Points M54.14, M54.6, M79.18
Patient: Cruz Jeffrey DOB: 02-22-1956 DOS: 09-27-2021 Location: 170 East Main Street Babylon NY 11702
Lumbosacral Sprain/Strain S33. 5XXA.
Lumbar Myalgia M79. 18.
Lumbar Trigger Points M54.16, M54.50, M79.18 Lumbago M54. 50
Left Lumbar Radiculopathy M54. 16.
LEFT SHOULDER
Left Shoulder Pain M25. 512.
Left shoulder strain/sprain S46. 919.
Left shoulder impingement M75. 42.
Left shoulder tendinosis M75. 82.
Left rotator cuff tear 546. 012A.
RIGHT SHOULDER
Right shoulder pain M25. 511.
Right shoulder strain/sprain S46. 919.
Right shoulder impingement M75. 41.
LEFT HIP
Left hip pain M25. 551.
Left piriformis strain S73. 102.
LEFT KNEE
Left Knee Pain M25. 562.
Left knee sprain S83. 8X9.
SACRUM
Left sacroiliac pain M53. 3.
Left sacroiliac strain/sprain S33. 6XXA.
PLAN
Lumbar trigger point injections today, well tolerated - Continue with present medications.
- Continue with Chiropractic treatment as per treating Doctor
- I have discussed several treatment options and the risks and benefits of conservative pain management treatment and continued physical therapy vs surgical and intervention treatment.
- I have stressed the importance of a home exercise program including stretching to maintain range of motion and improve overall function.
- I will schedule for knee injection next visit if symptoms persist and do not improve with therapy.
- The patient had a excellent response to todays trigger point injections and can be scheduled for further trigger point injections if their symptoms persist.
- The patient was given an appointment to follow up in 1 week or PRN for pain management.
Doctor Physician Assistant
Aman Deep MD Kathleen Egner
Patient: Cruz Jeffrey DOB: 02-22-1956 DOS: 09-27-2021 Location: 170 East Main Street Babylon NY 11702
