DISCHARGE SUMMARY
This 43-year-old male was admitted for intractable neck and right arm pain of a radicular nature. He had a cervical myelogram. The findings on myelography were a sharp extradural defect at the
C5-C6 level with deformation of the nerve root and narrowed foramina. The patient was seen in consultation, recommended surgical intervention. The patient will be discharged and think about his recommendations. His spinal fluid glucose was 68 with a protein 57.
C5-C6 level with deformation of the nerve root and narrowed foramina. The patient was seen in consultation, recommended surgical intervention. The patient will be discharged and think about his recommendations. His spinal fluid glucose was 68 with a protein 57.
FINAL DIAGNOSIS
Degenerative cervical disk disease with radiculopathy at C5-C6.
OPERATIONS
None.
CONDITION
Unchanged.
PROGNOSIS
Uncertain.
DISCHARGE INSTRUCTIONS
If he has any problems, he should contact me by phone. Otherwise, a routine appointment will be given in the next 1 to
2 weeks.
2 weeks.
FOOTNOTE
Line 17. Alternative: Disc.
Line 30. Alternative: 1-2.
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