ImranzamanML/Clinical_Documents_on_Syndromes_Disease

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COURSE:

MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV

but 1+ sharps and fibrillations in the right biceps (C5-6)

brachioradialis (C5-6)

triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.

The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.
CC:

Left third digit numbness and wrist pain.

HX:

This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.

SHX/FHX:

1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.

EXAM:

Vital signs unremarkable.

MS:

A & O to person, place, time. Fluent speech without dysarthria.

CN II-XII:

Unremarkable,MOTOR:

5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.

SENSORY:

Decreased PP in third digit of left hand only (palmar and dorsal sides).

STATION/GAIT/COORD:

Unremarkable.

REFLEXES:

1+ throughout, plantar responses were downgoing bilaterally.

GEN EXAM:

Unremarkable.

Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.

CLINICAL IMPRESSION:

Left Carpal Tunnel Syndrome,EMG/NCV:

Unremarkable.

MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.

COURSE:

The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.
EXAM:

MRI SPINAL CORD CERVICAL WITHOUT CONTRAST

CLINICAL:

Right arm pain, numbness and tingling.

FINDINGS:

Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.

At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.

At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.

At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.

A specific abnormality is not identified at the C7-T1 level.

IMPRESSION:

Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.
CC:

Sensory loss.

HX:

25y/o RHF began experiencing pruritus in the RUE

above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.

COURSE:

MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV

but 1+ sharps and fibrillations in the right biceps (C5-6)

brachioradialis (C5-6)

triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.

The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.

CC:

Left third digit numbness and wrist pain.

HX:

This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.

SHX/FHX:

1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.

EXAM:

Vital signs unremarkable.

MS:

A & O to person, place, time. Fluent speech without dysarthria.

CN II-XII:

Unremarkable,MOTOR:

5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.

SENSORY:

Decreased PP in third digit of left hand only (palmar and dorsal sides).

STATION/GAIT/COORD:

Unremarkable.

REFLEXES:

1+ throughout, plantar responses were downgoing bilaterally.

GEN EXAM:

Unremarkable.

Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.

CLINICAL IMPRESSION:

Left Carpal Tunnel Syndrome,EMG/NCV:

Unremarkable.

MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.

COURSE:

The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.

EXAM:

MRI SPINAL CORD CERVICAL WITHOUT CONTRAST

CLINICAL:

Right arm pain, numbness and tingling.

FINDINGS:

Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.

At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.

At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.

At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.

A specific abnormality is not identified at the C7-T1 level.

IMPRESSION:

Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.

CC:

Sensory loss.

HX:

25y/o RHF began experiencing pruritus in the RUE

above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.