CHIEF COMPLAINT: Neck, arm and back pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male, who presents with a complaint of several weeks of progressive neck, back and arm pain. The patient has a history of posttraumatic stress disorder and also he had cervical disk impingement in the remote past, at which point he had a cervical diskectomy and fusion of C5-C6 for similar symptoms. The patient states at that time, he had weakness to his arms and was unable to lift his hands above his head, and he had an emergent surgery. At this point, the patient states that he simply is having significant pain with movement of his arms. When he rides his motorcycle, he starts to get numbness down the posterior aspect of his arms. He does get numbness and tingling and he has hyperesthesias in bilateral arms, and he does intermittently get pain that shoots down his back. At this point, he denies any focal weakness. He denies any loss of coordination to the upper extremities. He denies any change in his bowel or bladder continence. The pain is 9-10/10. It is constant. It is nonradiating. It is not controlled with over-the-counter Tylenol or Motrin. The patient denies any acute change in his symptoms. He just woke up today, had severe pain and wants it to be evaluated.
REVIEW OF SYSTEMS: As per HPI, otherwise unremarkable. All systems reviewed and are negative.
PAST MEDICAL HISTORY: Posttraumatic stress disorder.
PAST SURGICAL HISTORY: Neck surgery as described.
SOCIAL HISTORY: Tobacco abuse.
FAMILY HISTORY: Noncontributory.
ALLERGIES: NKDA.
MEDICATIONS: Clonazepam and Zoloft.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: Alert and oriented, in no acute distress, moderate discomfort secondary to pain.
VITAL SIGNS: Blood pressure 152/94, pulse 68, respiratory rate 22, temperature 97.4, pulse oximetry 98% on room air, interpreted as normal. Pain is 10/10.
HEENT: Normocephalic and atraumatic. Pupils equally round and reactive to light. Tympanic membranes are normal. Oral mucosa within normal limits.
NECK: Supple. There is midline tenderness to palpation and paravertebral hypertonicity and tenderness and tenderness to palpation with limited cervical flexion range of motion; however, the rotation is intact.
HEART: Regular rate. No murmurs, 2+ pulses x4 extremities. Brisk capillary refill with warm sensation in bilateral hands. No evidence of peripheral vascular disease.
LUNGS: Clear to auscultation bilaterally, nontender chest wall.
ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds.
MUSCULOSKELETAL: There is cervical tenderness to palpation as described in neck examination. There is no thoracic or lumbar tenderness to palpation or hypertonicity. There is no deformity noted in the bilateral upper extremities. He has good muscle tone diffusely.
NEUROLOGIC: Cranial nerves II through XII grossly intact, nonfocal motor or sensory. He does have 5/5 grip strength in bilateral upper and lower extremities. He has intact fine touch sensation in his bilateral upper extremities. His coordination is normal. Finger-to-nose is intact. Gait is stable.
PSYCHIATRIC: Normal mood. Mentation, alert and oriented x4.
DIAGNOSTIC STUDIES: C-spine x-ray, there is noted C5-6 fusion intact. Cervical lordosis is intact. There is no evidence of fracture or subluxation. There are minimal osteoarthritic changes.
EMERGENCY DEPARTMENT COURSE: The patient was given Toradol and Percocet in the emergency room with significant pain relief. It was discussed in detail with the patient that he is showing signs of cervical radiculopathy, likely secondary to disk impingement. Recommendations to him at this point would be to have an outpatient MRI for consideration of additional surgery for symptom relief. It was also informed to the patient that given his lack of acute neurologic deficits, there is no evidence for need for emergent MRI or emergent surgical intervention. However, the risk of this developing in the future, if this problem is not addressed, is high and he needs to follow up as soon as possible as discussed. The patient understood all of these instructions and agreed to follow up as soon as possible.
IMPRESSION: Cervical radiculopathy and pain.
PLAN: The patient was discharged home with Lortab 5 mg and Motrin 800 mg.
DISPOSITION: Discharged to home.
