How To Write A Case Report: A 63-Year-Old Male Sales Patient

DOI: 9/9/2015. Patient is a 63-year-old male salesperson who sustained injury when he slipped on the showroom floor. As per OMNI entry, patient was diagnosed with left upper arm shoulder sprain.
MRI of the cervical spine without contrast done on 3/4/2016 revealed disc bulges and disc osteophyte complexes along the cervical spine with shallow posterior disc herniations at C4-C5, C5-C6 and C6-C7 level; these changes cause mild spinal canal narrowing. The changes at C4-C5 and C6-C7 slightly flatten the ventral surface of the cord. Facet arthropathy and uncovertebral spurring cause a few levels of foraminal narrowing.
She is status post transforaminal cervical epidural steroid injection at left C5 and C7 level per the procedure report dated 3/22/2016.

Robert, patient reports left upper extremity pain coming from her neck. She had injections in her shoulder from Dr. Wax, has physical therapy, as well as epidural steroid injection. She reports neck pain that radiates to her left upper extremity and elbow. She occasionally has some weakness in her hand as well. On examination, there is 1+ deep tendon reflexes in her upper and lower extremities. Range of motion of the cervical spine is decreased. There is tenderness to palpation on cervical spine with paraspinal muscle spasms. Patient was diagnosed with cervical radiculopathy.

Based on the progress report dated 09/20/16 by Dr. Robert, the patient reports that his pain has returned from the injection. He did great relief from the prior injection and she is ready to have surgery. Medical history includes hypertension, anemia, psychiatric problems and