LabDx
9/24/99
Article assignment is due a week from Monday, October 4th
History: A 67 y/o male complaining of neck pain radiating to the L shoulder of 4 months duration. Initially the aching pain involved the L shoulder, eventually progressing to the posterior c-spine. The pain was exacerbated by motion and recumbency. Supporting the head while sitting motionless reduced the pain. Numbness in the L upper extremity and progressive weakness in both extremities was noted. Two weeks prior to admission the pt noted generalized weakness and a 5-pound weight loss. The pt denied fever, GI or GU complaints, as well as c-spine trauma. Previous tx of the neck pain included a cortisone injection in the L shoulder, cervical traction, NSAIDS, and analgesics. Surgical Hx included venous stripping 21 years prior, and inguinal herniorrhaphy 9 years previously.
C/C—neck pain
O—4 months ago—chronic—insidious
P—exacerbated by motion and recumbency (no stress, should not be painful)
P—supporting the head while sitting—Rust Sign (pathologic etiology)
Q—aching pain (bone, tendon, ligament) (not nerve)
R—from L shoulder to posterior c-spine originally, now from neck to shoulder
S—severity—measure functional—neck is not functioning
T—
Associated Symptoms—weight loss, generalized weakness, numbness in upper shoulder
PE: The pt appeared WDWN but in mild distress 2° to neck pain. Vital signs were normal w/the exception of a BP of 160/100. HEENT was normal. ROM of the c-spine in all planes was severely reduced. The chest and abdomen were unremarkable. Atrophy of the supraspinatus and deltoid muscles was accompanied by mild B/L weakness in the biceps and deltoid muscles. The remaining musculature was normal. Reflexes were intact, except for the B/L absent tendon reflexes. Sensorium was negative. Spurling's test was normal.
Analysis: no biceps tendons, deltoids, biceps, level C5/6 (lower motor neuron) nerve root syndrome—radiculopathy
Working Dx—radiculopathy at C5/6
System or Systems
Differential for category (3)
Testing Strategy (justified)