Cervical spine

{Cervical spine}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms:
[-] neck pain
[-] neck stiffness
[-] torticollis

Right upper limb symptoms:
[-] pain
[-] sensory loss
[-] paraesthesia
[-] weakness
[-] wasting
Distribution:

Left Upper Limb Symptoms:
[-] pain
[-] sensory loss
[-] paraesthesia
[-] weakness
[-] wasting
Distribution: 
-

History of presenting complaint:
  Onset: 
  Location: 
  Severity (/10): 
  Quality: 
  Timing: 
  Context: 
  Aggravated by: 
  Relieved by:

Management to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
Relevant past medical history:
[-] Spinal injury 
[-] Spinal surgery

PHYSICAL EXAMINATION
Relevant examination findings:
[-] vertebral deformity 
[-] neck scars

Cervical spine active ranges of motion: {abnormalities}
[-] flexion [50+ deg.] 
[-] extension [60+ deg.] 
[-] lateral flexion [45+ deg.] 
[-] rotation [80+ deg.]

Cervical paraspinal muscle spasm: 
[-] right
[-] left

Upper limb muscle wasting: {abnormalities}
Arm circumferences measured the same distance above and below the elbows with the arm in a neutral posture (cm):
  Right upper arm:
  Right forearm: 
  Left upper arm: 
  Left forearm:

Upper limb motor power: 
Motor power grading: 0 = no contraction, 1 = slight contraction and no movement, 2 = active movement with gravity eliminated, 3 = active movement against gravity only, 4 = active movement against resistance but reduced, 5 = normal active movement against resistance.
  Right:
    5 : biceps - C5, C6 
    5 : triceps - C6, C7 
    5 : wrist extension - C6, C7, C8, radial nerve 
    5 : grip - C7, C8, T1 
    5 : finger abduction - C8, T1, ulnar nerve 
    5 : thumb opposition - C8, T1, median nerve 
  Left:
    5 : biceps - C5, C6 
    5 : triceps - C6, C7 
    5 : wrist extension - C6, C7, C8, radial nerve 
    5 : grip - C7, C8, T1 
    5 : finger abduction - C8, T1, ulnar nerve 
    5 : thumb opposition - C8, T1, median nerve

Grip strength: {abnormalities}
  Right (kg): 
  Left (kg):

Upper limb deep tendon reflexes: 
Reflex grading: 0 = no response, 1 = decreased, 2 = normal, 3 = increased, 4 = increased with clonus.
  Right:
    2 : biceps jerk - C5, C6 
    2 : supinator jerk - C6 
    2 : extensor digitorum jerk - C6, C7 
    2 : triceps jerk - C7, C8 
  Left:
    2 : biceps jerk - C5, C6 
    2 : supinator jerk - C6 
    2 : extensor digitorum jerk - C6, C7 
    2 : triceps jerk - C7, C8

Sensation: (Light touch, pinpoint) 
Sensory grading (compare with the face as the normal control): 0 = absent (anaesthesia), 1 = altered or reduced, 2 = normal.
  Right:
    2 : C4 - posterior aspect of shoulder 
    2 : C5 - lateral aspect of upper arm 
    2 : C6 - tip of thumb 
    2 : C7 - tip of middle finger 
    2 : C8 - tip of pinkie 
    2 : T1 - medial aspect of lower arm 
  Left:
    2 : C4 - posterior aspect of shoulder 
    2 : C5 - lateral aspect of upper arm 
    2 : C6 - tip of thumb 
    2 : C7 - tip of middle finger 
    2 : C8 - tip of pinkie 
    2 : T1 - medial aspect of lower arm

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
[-] X-ray Cervical spine 
[-] CT Cervical spine 
[-] MRI Cervical spine

Referrals:
-

Information and advice given:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260131]

Cervical spine

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