Final 1 Bmt
HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT
Herniated cervical disk.
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 had intermittent paresthesia which has been increasing to the point where she now claims that she has a large amount of paresthesias 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 C4-5 and C5-6.
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 SURGICAL HISTORY
Diagnostic and operative arthroscopy of the right knee in 1984. Right knee surgery in 1985 with transfer of the tibial tubercle. Hysterectomy in 1983. 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, 1 with lung cancer and the other with throat cancer.
ALLERGIES
Penicillin which causes hives, and erythromycin which causes nausea, vomiting, and hives.
MEDICATIONS
Percodan 1 - 2 p.o. q.d, and Flexeril 1 p.o. q.6h.
REVIEW OF SYSTEMS
Noncontributory.
PHYSICAL EXAMINATION
GENERAL APPEARANCE: This is
CHIEF COMPLAINT
Herniated cervical disk.
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 had intermittent paresthesia which has been increasing to the point where she now claims that she has a large amount of paresthesias 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 C4-5 and C5-6.
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 SURGICAL HISTORY
Diagnostic and operative arthroscopy of the right knee in 1984. Right knee surgery in 1985 with transfer of the tibial tubercle. Hysterectomy in 1983. 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, 1 with lung cancer and the other with throat cancer.
ALLERGIES
Penicillin which causes hives, and erythromycin which causes nausea, vomiting, and hives.
MEDICATIONS
Percodan 1 - 2 p.o. q.d, and Flexeril 1 p.o. q.6h.
REVIEW OF SYSTEMS
Noncontributory.
PHYSICAL EXAMINATION
GENERAL APPEARANCE: This is