Cervical Spine Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 50y/o complains of neck, shoulder, and arm pain. Notes occasional paresthesias and numbness mainly in hand. Denies occipital headache or jaw ache. Pain is 3-7/10. Worse with prolonged activity and any bending or lifting. No noted weakness. No bowel, bladder or sexual dysfunction. Pain is improved with bedrest. No night pain. Previous treatment: NSAIDs, narcotic pain meds. no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Medications:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Gait: normal
Skin / Lymph: normal, no scars
Tenderness: none
Flexion: 45
Extension: 45
Lateral Bend(R/L): 45 /45
Rotation (R/L): 80 / 80
Spurling’s test positive (R/L): - / -
C5 (Deltoid / lateral arm sensation / Biceps)= 5/5 : normal / 2+
C6 (Wrist Extension / Lateral forearm sensation / Brachioradialis)= 5/5 : normal : 2+
C7 (Triceps / Middle finger sensation / Triceps reflex)= 5/5 : normal : 2+
C8 (Interossei / ulnar forearm)= 5/5 : normal
T1 (Interossei / Medial arm)= 5/5+ : normal
Waddell Signs: -tenderness, -simulation, -distraction, -regional disturbances, -overreaction
Clonus (R/L): - / -
Babinski (R/L): - / -
Radial Pulse (R/L): 2+ / 2+
Xray: Mild disk space narrowing. Mild facet arthropathy.
MRI: none
ASSESSMENT: Cervical Radiculopathy ()
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Physical Therapy / traction
AAOS info
NSAIDS
Follow-up 6-8 weeks