Some differential diagnosis to consider include: Cervical disc bulge with neuropathy, cervical sprain/strain, thoracic outlet syndrome
Physical Examination Findings:
Wt = 175, Ht = 5 feet 11 inches, Temp = 37, P = 80, Resp = 12, Rt. BP = 124/84 (seated)
Cervical examination revealed pain in right lateral flexion, right rotation and forward flexion. Joint restrictions were noted at C2-4 facets on the left and C6 on the right. There was marked tenderness over the C7 spinous process with painful response to 128 Hz tuning fork vibration testing. The left levator muscle was tender to palpation with trigger points noted. There was no frank spasm, swelling, warmth or discoloration of the neck. Upper extremity strength, pulse and deep tendon reflexes were within normal limits. DTRs were brisk bilaterally in the upper extremities. There was no loss of sensation to pinprick nor vibration in the hands or fingers. Cervical compression and distraction testing were negative for neural signs. Maximal foraminal compression testing to the left caused moderate left sided neck pain. Cranial nerve exam was unremarkable.
Question: What is the working diagnosis?
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