DOI: 1/24/2008. Patient is a 57-year old male medical assistant who sustained injury to her neck and right shoulder due to performing normal work duties. Per OMNI, he was initially diagnosed with cervical radiculopathy and stenosis. He was declared P & S by primary treating physician Dr. Chan on 07/23/09 with 9 % permanent disability (PD). Future medical care includes MD visits, ESIs, acupuncture and medications.
MRI of the cervical spine obatiened on 12/01/08 showed degenerative changes most prominent at C5-6 and C6-7 where broad-based disc protrusion combine with disc bulging and uncovertebral hypertrophy to cause moderate bilateral neural foraminal narrowing, greater on the right at C5-6 level and greater on the left at C6-7 level, as well as mild narrowing of the central canal.
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Per progress report dated 11/07/12, the patient felt much better after the injection. The paresthesias have resolved and the pain has decreased. Level of pain is 1-2/10, which was 5-10/10 previously.
Based on progress report dated 07/28/15, the patient was last seen on 2/11/2014. She has experienced a flare of left neck pain radiating down the left arm to the hand and third and fourth fingers. Pain is rated as 9/10. She uses tramadol once per week, Relafen once to twice daily and Prilosec daily. She is working.
On examination, Spurling test is positive the left with radicular pain and symptoms radiating down the arm. Manual muscle testing was intact at the upper extremities. Sensation to touch was diminished at the left third finger. Muscle stretch reflexes revealed relative left triceps hyporeflexia. Palpation produced tenderness at the left mid and lower cervical paraspinals.
Diagnoses are flare of cervical foraminal stenosis with left C7 radiculopathy and myofascial