Office Note Sample:

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OFFICE NOTE

RE:   Debra Jones
DATE 12/01/10
MR:  240804
DOB: 12/01/65

HISTORY:  Debra returns today after a visit with Dr. Harry Richard.  At that time he suggested cervical epidural steroid injection.  The patient was given Percocet 7.5/325 to take prior to the procedure.  She did not schedule the procedure because her symptoms decreased.  The pain level at the present time is 3-4/10 with pain that is extending to the right upper extremity from the right shoulder on the lateral and the anterior aspect of the upper arm to the elbow but not into the hand.  She gets occasional paresthesias in the right thumb but no apparent weakness.

PHYSICAL EXAMINATION:  Reflexes intact bilaterally in the biceps, triceps, and brachioradialis.  No difficulty with position of the first and second fingers.  Mobility of the fingers, wrists, elbows, shoulders were all within normal limits.  Examination of the neck by palpation:  No pain on palpation of the superior transverse processes.  There is paravertebral muscle tenderness at C5-C6 bilaterally but no suprascapular tenderness.  Cranial nerves II-XII appear intact. 

IMPRESSION: 
1.   Displaced disc at C-C6.
2.   C5-C6 radiculopathy.

PLAN:  Continue Percocet and continue physical therapy.  She has finished chiropractic therapy.  She was warned about signs of increasing weakness such as inability to hold objects in her hand and difficulty moving her right thumb.  Should anything occur like that or any weakness she will return immediately.  In the meantime, she will be treated with medications and physical therapy.  We will consider epidural steroid injections if symptoms worsen.