The Lord
诉：颈项部疼痛伴双上肢麻木
Sue:
neck pain and upper limb numbness
2
2
月余。
More than a month.
现病史：患者素有颈项部疼痛病史，于
History: the patient has a
history of
neck pain, to
2
2
月前无明显诱因出现颈项部疼痛伴双上肢麻木，
Without apparent inducement occurrence neck pain with double upper limbs numbness months ago,
未予重视，
Do not pay attention to,
休息后症状未见缓解，
The symptoms were not relieved after rest,
自服活血止痛药后颈项部疼痛缓解，
Self
service
Huoxue
painkillers
neck pain
relief,
双上肢麻木改善不明显，
Double upper limbs numb no obvious improvement,
停药后复发，就诊于武警医院，行颈椎
Relapse after stopping, visits to the Armed Police Hospital, cervical spine
MRI
MRI
提示：
Prompt.
C6-7
C6-7
椎间盘轻度突出，为求系统治疗，遂于
Disc slightly prominent, for the sake of the treatment system, and to
今日就诊我院，门诊以“颈椎病”收住本科。刻下：颈项部疼痛伴双上肢麻木，颈椎活动轻度
Today's visit in our hospital,
outpatient service with "cervical spondylosis"
admitted to
undergraduate. At
the moment: neck pain with double upper limbs numbness, mild cervical activity
受限，双上肢下垂时麻木症状加重，平放时症状减轻，长时间低头及劳累后症状明显加重，休
Limited,
double upper limbs
muscle
numbness
symptoms, when laid flat to alleviate the
symptoms, long
time head and exertional symptoms increase, Hugh
息后缓解，双上肢肌力无异常，偶见头痛头晕，未见晕厥，无夜间加重，双下肢踩棉花样感不
After
remission, double upper limbs strength without exception, I
see no headache and
dizziness, syncope, no nightly accentuation,
double lower limbs
on the
cotton
like not
feeling
明显，纳可，眠安，二便可，舌质红，苔白，脉细数。
Obviously,
nake, Mian an, two can,
red tongue, moss white, pulse counting.
既往史：否认结核等传染病史及密切接触史。否认药物、食物过敏史。预防接种史不详。
Past history:
denial of
tuberculosis and other infectious disease history and history of close contact. Deny drug,
food
allergies. Vaccination history is unknown.
有肝炎病史
With a history of hepatitis
2
2
年。
Years.
个人史：生于原籍，无外地长期居住史，无疫区居住史。平素生活规律，无吸烟史，无毒
Personal history: in the country of origin, no field of long-term residential history, history of living in non endemic area.
Usually the law of
life, no smoking, no
物接触史。
Contact history.
婚育史：适龄结婚，配偶及子女均健康。
Obstetrical history:
age of
marriage, spouses
and children
are
healthy.
体
Body
格
Lattice
检
Check
查
Check
T:36.5
T:36.5
℃
C
P:74
P:74
次
Time
/
/
分
Divided
R:20
R:20
次
Time
/
/
分
Divided
BP:110/80mmHg
BP:110/80mmHg
发育正常，营养中等，自动体位，查体合作，神志清楚，回答切题。全身皮肤、粘膜无黄
The development of normal, nutrient medium,
automatic
position, check cooperation, sane,
answer to the
point. Systemic skin, mucous membrane without yellow
染、皮疹及出血点，无肝掌、蜘蛛痣，浅表淋巴结未触及肿大。头颅外形正常，眼球无外凸、
Dye,
rash and bleeding, no liver palm, spider nevus, superficial lymph node with no palpable. The cranial shape normal,
non
convex
eye,
内陷。眉毛无稀疏、脱落。双眼睑无下垂、浮肿，球结膜未见水肿，睑结膜无充血，巩膜无黄
Invagination.
Sparse
eyebrows, without shedding. Eyelid droop,
no edema, conjunctival no edema, conjunctival no congestion,
no
yellow
sclera
染，
Dye,
两侧瞳孔等大等圆，
Bilateral pupil wait for a circle greatly,
直径
Diameter
3mm
3mm
，
,
对光反射灵敏。
The light reflex sensitivity.
双耳听力正常，
Binaural hearing,
外耳道通畅，
The external auditory canal,
无异常分泌物，
No abnormal secretions,
乳突无压痛。鼻外形正常，无异常分泌物，副鼻窦无压痛。口唇无紫绀，口周无疱疹，口腔粘
Mastoid no tenderness.
Nose is
normal, no
abnormal
secretions, paranasal sinus without tenderness. No lips cyanosis, mouth weeks without bleb, buccal adhesive
膜无溃疡，牙龈无红肿，伸舌居中，咽部无明显充血，扁桃体不大。颈无抵抗，颈静脉无怒张，
Film without ulcers,
gingival swelling
without, tongue is no obvious hyperemia,
pharynx, tonsil is not.
Neck no
resistance, no jugular vein engorgement,
肝
Liver
-
-
颈静脉回流征阴性
Jugular venous reflux sign negative
,
,
气管居中，甲状腺未触及肿大。胸廓对称无畸形，右侧呼吸动度正常，
Tracheae, no palpable thyroid. Symmetric non thoracic deformity, on the right side of the normal respiratory motion,
右侧语颤正常，
The right language fibrillation to normal,
无胸膜摩擦感。
No sense of pleural friction.
双肺叩清音，
Double lung percussion sound,
双肺呼吸音清晰
Double lung breathes phonic clarity
,
,
无干湿性啰音，
No
dry and wet
rales,
未闻及胸膜摩擦
No pleural friction
音。
Sound.
心前区无隆起，
Free zone uplift before the heart,
无异常搏动，
No abnormal pulse,
心尖搏动点未见，
Apex beat no,
触无震颤，
Touch no
tremor,
心界不大，
Heart group is not big,
心率
Heart rate
74
74
次
Time
/
/
分，
Divided,
律齐，
The law is neat,
心音低钝，各瓣膜听诊区未闻及病理性杂音，未闻及心包摩擦音。
Heart sounds is low blunt, area of each valve auscultation without pathological murmur, no pericardial friction sound.
专科检查：颈椎曲度变直，颈部肌肉僵硬，颈椎活动轻度受限，颈
Specialized examination:
cervical curvature
becomes straight, stiff neck muscles, and cervical spine slightly restricted, neck
4-
4-
颈
Neck
6
6
棘间压痛（
Interspinous tenderness (
+
+
）
)
，
,
颈
Neck
3-
3-
颈
Neck
6
6
棘旁两侧压痛（
Paraspinal tenderness (both sides
+
+
）
)
，叩击痛（
,
percussion pain (
-
-
）
)
，双侧椎间孔挤压试验（
,
bilateral intervertebral foramen extrusion test (
-
-
）
)
，叩顶试验（
Knock test (top,
-
-
）
)
，臂丛牵
Brachial plexus traction,
拉试验左侧（
The left (tensile test
+
+
）
)
、右侧（
,
(on the right
side
+
+
）
)
，旋颈试验（±）
,
neck rotation test
(±)
，双上肢肌力正常，肱二、肱三肌腱反射正常，双
Normal,
double upper limbs
strength of
two, three, triceps tendon reflex is normal, double
侧霍夫曼征（
Hoffman syndrome (side
-
-
）
)
，余病理反射未引出。
No
more than, pathology
reflex.
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