FE Report

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT

Herniated cervical disc.

HISTORY OF PRESENT ILLNESS

This is a 35-year-old white female with cervical pains.  She was involved in a car accident 8 years prior to this with no history of neck pain and has developed progressive neck pain since the end of the last year.  She was initially treated with physical therapy, support, and medication with only minor relief.  More recently, the pain has been increasing, radiates from the base of the occiput, down to the neck, and into both arms.  The pain was originally intermittent but has been increasing with time.  She originally has intermittent paresthesia, which have been increasing to the point where she now claims that she has a large amount of paresthesia in the entire right arm and of the left index and long fingers.  She claims to have some weakness in the right arm as compared to the left.  She has no bowel or bladder symptomatology.  MRI scan has reportedly shown central herniation at C4-C5 and C5-C6.

PAST MEDICAL HISTORY

Negative for seizures, diabetes, hypertension, heart disease, lung disease, asthma, chest pain, shortness of breath, peptic ulcer disease, hepatitis, liver disease, or kidney diseases.

PAST MEDICAL HISTORY

1. Diagnostic and operative arthroscopy of the right knee in 1984.

2. Right knee surgery in 1985 with transfer of the tibial tubercle.

3. Hysterectomy in 1983.

4. Tubal ligation in 1979.

SOCIAL HISTORY

She is a housewife and is married.  Smoking half-a-pack per day.  Alcohol none.

FAMILY HISTORY

Her father is deceased secondary to lung cancer.  Her mother is deceased secondary to heart disease.  Her sister has diabetes and 2 brothers who have cancer, one with lung cancer and the other with throat cancer.  (Poor girl!)

ALLERGIES

PENICILLIN, WHICH CAUSES HIVES AND ERYTHROMYCIN, WHICH CAUSES NAUSEA, VOMITING, AND HIVES.

MEDICATIONS

Percodan 1 to 2 p.o. q.d. and Flexeril 1 p.o. q.6h.

REVIEW OF SYSTEMS

Noncontributory.

PHYSICAL EXAMINATION

GENERAL APPEARANCE:  This is a well-developed, well-nourished white female who is status post cervical myelogram today.

VITAL SIGNS:  She has a pulse of 76, blood pressure of 110/80, temperature is 98.7, respirations are 20, and weight is
156 pounds.

HEAD, EYES, EARS, NOSE, AND THROAT:  Atraumatic and normocephalic.  Pupils are equal, round, reactive to light and accommodation.  Extraocular movements are intact.  The sclerae are white and conjunctivae are pink.  The pharynx is without lesion or exudate.

NECK:  There is a paraspinal muscle spasm in the cervical region along the tenderness.  This is diffuse from the base of the occiput to C7.  She has decreased range of motion secondary to pain.

LUNGS:  Clear to auscultation both anteriorly and posteriorly.

BREASTS:  There are no masses, lesions, or exudates.  There is a well-healed surgical scar above the right nipple.

HEART:  Regular rate and rhythm without rubs, gallops, or murmurs.

SPINE:  Nontender in the thoracic and lumbar regions.

ABDOMEN:  Bowel sounds are positive.  Soft and nontender.

RECTAL:  Deferred as the patient is 35 years of age.

NEUROLOGICAL:  The patient claims to have a marked decrease in sensation from the right shoulder to the right fingertips diffusely.  She does not respond to pinch or to sharp pain.  She has decreased sensation to the left index and long fingers.  The motor strength is 5/5 for the deltoid, biceps, triceps, wrist flexors, wrist extensors, and intrinsics for both the right and left, although there is some decrease on the right which appears to be secondary to pain.  The lower extremities have 5/5 muscle strengths for all motor groups.  There is no calf pain noted.  There is a 2+ pulse for the radial, dorsalis pedis, and posterior tibial pulses.  The deep tendon reflexes are 2+ for biceps, triceps, brachioradialis, knee flexion, and knee extension.

IMPRESSION

Herniated cervical disc.

PLAN

Myelogram today and an anterior cervical fusion tomorrow.