Solomon Sallfors: Ambulatory Morning Report 1: ARM PAIN

Chief Complaint: Arm Pain

HPI: 54 yo man with insignificant PMHx presents with arm pain for 1 year. He injured his right
arm at work while carrying a heavy object on his shoulder. Its weight shifted and exerted a
downward and lateral force on his shoulder. The injury was very painful. He took one day off
work to rest the arm. Over the past year, he has had constant arm pain, dull in character with
intermittent exacerbations of sharp pain, which comes on with suddenly with work and at rest,
exacerbations mostly lasting less than an hour and rated 10/10. Exacerbations are associated with
shocking pain from paraspinal region down lateral upper arm. Patient also discloses multiple
times in which his arm becomes numb and goes to sleep requiring him to conduct arm
maneuvers, which relieve this numbness. Patient refuses pain medications. He comes to the
clinic make sure theres nothing serious going on.
Meds: None. Surgeries: None. Allergies: None. FMHX: HTN, HLD. PMHx: HTN,HLD.
SOCIAL: No Alc/tob/drugs. Married with 2 adult children. Employed as handyman at church
>10yrs. ROS: Neg except as in HPI.
PE: Vitals: 135/85. 75HR 12RR O2SATs 98% Temp 89.9. Gen: Well dev, well nourished man
who looks his stated age, greater than average muscle mass with some obvious excess body fat,
well kept and appropriately dressed, in no apparent distress. Neuro: Normal affect, thought
processes, and general behavior. CN2-12 grossly intact. 5/5 muscle strength throughout. Reflexes
triceps, biceps, and brachioradialis +2. Sensation is grossly intact. No numbness, spasticity,
abnormal movements or tremors, or rigidity. Musculoskeletal: Nl size, tone, and ROM in major
muscle groups, including right upper extremity, with some increased tone in the paraspinal
region on the right around C5-7. Special Tests: Neg including drop arm, empty can, left-off,
Yergason's, Hawkins, AC joint tenderness, Spurlings, Speeds, Apprehension. PSYC: no
anhedonia, no worthlessness. Other systems normal.
Labs: None.
Diagnosis: Cervical radiculopathy. Etiology disc herniation (acute onset, likely C5) vs cervical
spondylosis (less likely chronic condition).
Work UP: MRI.
Treatment: For patients with cervical radiculopathy who have clear radicular pain and
symptoms of paresthesia, numbness, or nonprogressive neurologic deficits, initial therapy is
conservative: NSAIDs, avoidance of provocative activities, and poss short course of
oral prednisone if pain is severe. With pain controlled, patient can start physical therapy. 1/3 of
patients will have symptoms recur, after which conservative therapy should be restarted. Surgery
is an option with motor weakness impairing function or pain after 6-12 weeks.
Our Patient: Refused medications. Consented to MRI. He will follow up with physical therapy.