Sample Name: MRI C3 - Cord Compression.
Description: Left third digit numbness and wrist pain.
(Medical Transcription Sample Report)
CC: Left third digit numbness and wrist pain.
HX: This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.
SHX/FHX: 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.
EXAM: Vital signs unremarkable.
MS: A & O to person, place, time. Fluent speech without dysarthria.
CN II-XII: Unremarkable
MOTOR: 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.
REFLEXES: 1+ throughout, plantar responses were downgoing bilaterally.
GEN EXAM: Unremarkable.
Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.
CLINICAL IMPRESSION: Left Carpal Tunnel Syndrome
MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.
COURSE: The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.
Keywords: neurology, wrist pain, spondylosis, disc bulge, digit numbness, mri, atrophy, numbness, wrist,