Some of the diagnoses you should consider include, disk herniation, thoracic outlet syndrome, myofascial dysfunction, cervical spine fracture, cervical myelopathy.

Physical Examination Findings:

Weight = 180lbs, Height = 5’9”, Temperature= 98.9F, Respirations = 12cpm, and Blood Pressure = 122/82 mmHg

Inspection:

A large lipoma-like mass (5” x 4”) by inspected on the left scapula.  The patient stated he has this mass as long as he could remember, and his PCP was not concerned about it.  Large mid-spinal scar (T12-S1) from lumbar laminectomy is present.  Popeye’s sign on right bicep.  Severe forward head carriage.  Hypertonic paraspinals in the lumbar spine and thoracic spine. Atrophy noted in the supraspinatus muscle bilaterally.

Palpation:

Patient demonstrated extreme sensitivity to touch and palpation in all areas of the body, needed to take a break at times. Specifically, there was extreme subjective pain in the upper trapezius muscle bilaterally, and with palpation of the C7 vertebrae.  Tenderness noted along each vertebrae in the lumbar and thoracic spine. Several areas of the cervical spine had motion restrictions (C0/C1 right lateral flexion restriction, C4/C5 left rotation restriction).

ROM: Baseline Cervical Active ROM (AMA guidelines) vs. measured. Due to patient’s pain level, inclinometry was contraindicated due to the patient’s inability to sustain a motion for more than one second.

                               NORMAL                         MEASURED (2/3/15)

Flexion                          60                                        60

Extension                      75                                        15 (with pain at central C7/T1 region)

Left LF                          45                                        25 (with pain at central C7/T1 region)

Right LF                        45                                        25 (with pain at central C7/T1 region)

Left rotation                  80                                        40 (with pain at central C7/T1 region)

Right rotation                80                                        40

Orthopedic testing:

Neurologic testing was performed. All cranial nerves were normal and intact. Mr. X  had a decreased light touch sensation in the right C8 dermatome.  He also had a decreased sharp sensation in the right C8 and T1 areas. Upper and lower extremity myotomes were within normal limits.  Upper and lower extremity reflexes were 0/4+J.

The following tests were positive:

-        Spurling A for cervical spine on the right

-        Cervical distraction

-        Maximum cervical compression bilaterally.

The following tests were negative (and normal is to be negative)

-        L’Hermittes

Question: What is your working diagnosis at this point?  What imaging, or laboratory testing would you order?