Cervical Spine Note

#Cervical Spine S: Subjective Presenting Complaint: Cervical Spine Symptoms: (-) neck pain (-) neck stiffness (-) torticollis (-) other/s -> Right Upper Limb Symptoms: (-) pain (-) sensory loss (-) paraesthesia (-) weakness (-) wasting (-) other -> distribution: Left Upper Limb Symptoms: (-) pain (-) sensory loss (-) paraesthesia (-) weakness (-) wasting (-) other -> distribution: Symptom Development: - Onset/triggers: - Aggravating factors: - Relieving factors: Past Medical History: (-) Injury (-) Surgery (-) Other -> O: Objective 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: Arm circumferences measured the same distance above and below the elbows with the arm in a neutral posture. (-) Right upper arm (-) Right forearm (-) Left upper arm (-) Left forearm Upper Limb Motor Power: **abnormalities** 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, NT = not testable. Right: (-) biceps (C5, C6) (-) triceps (C6, C7) (-) wrist extension (C6, C7, C8, radial nerve) (-) grip (C7, C8, T1) (-) finger abduction (C8, T1, ulnar nerve) (-) thumb opposition (C8, T1, median nerve) Left: (-) biceps (C5, C6) (-) triceps (C6, C7) (-) wrist extension (C6, C7, C8, radial nerve) (-) grip (C7, C8, T1) (-) finger abduction (C8, T1, ulnar nerve) (-) thumb opposition (C8, T1, median nerve) Grip strength: *abnormalities* (-) Right (kg): (-) Left (kg): Upper Limb Deep Tendon Reflexes: **abnormalities** Reflex grading: 0 = no response, 1 = decreased, 2 = normal, 3 = increased, 4 = increased with clonus, NT = not testable. Right: (-) biceps jerk (C5, C6) (-) supinator jerk (C6) (-) extensor digitorum jerk (C6, C7) (-) triceps jerk (C7, C8) Left: (-) biceps jerk (C5, C6) (-) supinator jerk (C6) (-) extensor digitorum jerk (C6, C7) (-) triceps jerk (C7, C8) Sensation: (Light touch, pinpoint) *abnormalities* Sensory grading (compare with the face as the normal control): 0 = absent (anaesthesia), 1 = altered or reduced, 2 = normal. Right: (-) C4 (posterior aspect of shoulder) (-) C5 (lateral aspect of upper arm) (-) Right 2, Left 2: C6 (tip of thumb) (-) Right 2, Left 2: C7 (tip of middle finger) (-) Right 2, Left 2: C8 (tip of pinkie) (-) T1 (medial aspect of lower arm) Left: (-) C4 (posterior aspect of shoulder) (-) C5 (lateral aspect of upper arm) (-) Right 2, Left 2: C6 (tip of thumb) (-) Right 2, Left 2: C7 (tip of middle finger) (-) Right 2, Left 2: C8 (tip of pinkie) (-) T1 (medial aspect of lower arm) Investigation Results: A: Assessment Clinical Summary: Diagnosis / DDx: P: Plan Investigations: (-) X-ray cervical Spine (-) CT cervical spine (-) MRI cervical spine Treatment: Referrals: Patient Education / Home Care Advice: Review:

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