The patient presents herself to the physical medicine and rehabilitation clinic today with a
chief complaint of itching in her right arm. She is a 72-year-old, right-handed female
who began to notice some rash over the dorsum of the right wrist which gradually spread
over to the forearm and upper arm only on the lateral aspect. She was seen by two
dermatologists and it was felt that her itching was from neurological causes. She was
given local cream application which has not helped. She is taking some anti-itch
medications with slight benefit. The itching seems to be getting worse. She noticed the
itching is worse at night but has nothing to do with the temperature. She will wake up at
night because of that, even after taking Ambien. She denies numbness, weakness, or
pain. She does have some tingling deep inside in the right upper extremity. She is not
taking any pain medication. Ice does help some. She underwent a cervical MRI
10/27/07 which showed multi-level degenerative changes at C5-6 and C6-7 with severe
neural foraminal narrowing on the right at C5-6. Neural foraminal stenosis on the left at
C3-4 and C2-3 due to facet hypertrophy was noted.
ALLERGIES: No known drug allergies.
PAST SURGICAL HISTORY: Status post cholecystectomy and cataract surgery.
CURRENT MEDICATIONS: Lexapro, bupropion, flecainide, diltiazem, Isordil.
FAMILY HISTORY: Positive for cancer.
REVIEW OF SYSTEMS: Positive headache on 12-system review.
SOCIAL HISTORY: She does not smoke or drink. She is divorced and does not do
exercise.
PHYSICAL EXAMINATION: The patient is pleasant, in no acute distress. There are
more pinkish papules scattered over the dorsum of the right forearm and upper arm.
There is no local heat or redness around the skin lesions. Deep tendon reflexes are 2+
and symmetric. Sensory exam is normal to light touch and pinprick with detailed
examination. Muscle strength is 5/5 throughout. Range of motion of the neck is within
normal limits. Spurling's is negative bilaterally. There is no cervical muscular
tenderness. Tinel's is negative bilaterally. Fabere sign negative bilaterally. Wrist sign
negative bilaterally. Range of motion of the right shoulder, elbow, and wrist is normal
bilaterally. There is no tenderness at the lateral and medial epicondyles bilaterally.
ASSESSMENT: This is a 72-year-old female who presents with chronic itching and
tingling along the dorsal right upper extremity. The history and clinical exam are
suggestive of right C5-6 radiculitis. However, she does not have typical positive and
negative neurological signs and usual presentation for cervical radiculitis.
TREATMENT PLAN: My impression was discussed with the patient. I indicated to her
and her son that it would be prudent to have a therapeutic trial of Neurontin to see if she
does respond to that or not. Detailed instructions on the use of Neurontin were provided.
She is to call me for any questions regarding the use of the medication. She will return to
clinic in three weeks for followup.
I will re-evaluate her progress and recommend further treatment at that time.