DOI: 5/16/2016. Patient is a 45-year-old male laborer who sustained a work-related injury to his head and neck when a concrete form panel fell while he was carrying it. As per OMNI notes, patient was initially diagnosed with neck sprain.
CT scan of the cervical spine without contrast performed on 5/16/2016 revealed unremarkable results.
MRI of the cervical spine dated 06/26/16 showed the following: central herniation at C2-3 with inferior extrusion, impinging upon cord, age indeterminate; central herniation at C3-4 with cord impingement, the herniation containing gradient echo byperintensity, indicating an acute herniation; right paracentral herniation at C4-5 with thecal sac indentation, age indeterminate; right paracentral herniation at C5-6 with inferior extrusion, impinging upon originating C7 nerve root, containing gradient echo hyperintensity, thus acute in nature; bulging disc at C6-7 without stenosis, age indeterminate; and non-acute retrolisthesis and levels of disc …show more content…
Based on the latest medical report dated 11/17/16, the patient returns for reevaluation of his neck pain and right arm numbness.
Patient complains of pain and stiffness in his cervical spine. He complains of numbness in his right hand, especially his middle finger. Patient states that the issue is staying the same and the pain keeps him up at night. Any exercise, sitting, standing, walking, repetitive motion causes the pain to become worse. Patient rates the pain as a 8 out of 10. Patient has not worked since the accident. Patient has been in physical therapy and taking anti-inflammatories as well as had multiple epidural injections without relief. Patient states he is having erectile dysfunction.
On examination of the cervical spine, there is pain to palpation at the paraspinal musculature. Right biceps power is 4/5.
Sensation is decreased in right and left C5-6
CT scan of the cervical spine without contrast performed on 5/16/2016 revealed unremarkable results.
MRI of the cervical spine dated 06/26/16 showed the following: central herniation at C2-3 with inferior extrusion, impinging upon cord, age indeterminate; central herniation at C3-4 with cord impingement, the herniation containing gradient echo byperintensity, indicating an acute herniation; right paracentral herniation at C4-5 with thecal sac indentation, age indeterminate; right paracentral herniation at C5-6 with inferior extrusion, impinging upon originating C7 nerve root, containing gradient echo hyperintensity, thus acute in nature; bulging disc at C6-7 without stenosis, age indeterminate; and non-acute retrolisthesis and levels of disc …show more content…
Based on the latest medical report dated 11/17/16, the patient returns for reevaluation of his neck pain and right arm numbness.
Patient complains of pain and stiffness in his cervical spine. He complains of numbness in his right hand, especially his middle finger. Patient states that the issue is staying the same and the pain keeps him up at night. Any exercise, sitting, standing, walking, repetitive motion causes the pain to become worse. Patient rates the pain as a 8 out of 10. Patient has not worked since the accident. Patient has been in physical therapy and taking anti-inflammatories as well as had multiple epidural injections without relief. Patient states he is having erectile dysfunction.
On examination of the cervical spine, there is pain to palpation at the paraspinal musculature. Right biceps power is 4/5.
Sensation is decreased in right and left C5-6