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Name ___________________________________________________DOB _______________________ Med Record No. _________________________________NEUROGENIC TOS: FIRST VISIT This datasheet: RIGHT ARM LEFT ARMOther symptoms?VTOSATOSContralat NTOSDATE:_________________________________Current age _____________________________________DEMOGRAPHICS Gender:MaleFemaleHandedness:LeftRightAmbidextrousCurrently:Employedin SchoolDisabledRetired Side(s) affected: Right Right more than left Left more than right LeftBoth equallyThe following pertain to the RIGHTLEFTarmHISTORYSymptoms:Began:<3 mos3-6 mos6-12 mos1-2 yrs2-5 yrs>5yrs agoSleepingUnaffectedPain on affected side Symptoms at rest/with normal activities:NumbnessShoulderUpper armForearmHand 1-3Hand 4,5TinglingShoulderUpper armForearmHand 1-3Hand 4,5Pain ShoulderUpper armForearmHand 1-3Hand 4,5 WeaknessShoulderUpper armForearmHand 1-3Hand 4,5SwellingShoulderUpper armForearmHand 1-3Hand 4,5DiscolorationShoulderUpper armForearmHand 1-3Hand 4,5Other symptoms:Head/headache:________________________________________________________________Neck:_________________________________________________________________________Trapezius:_____________________________________________________________________Chest wall:_____________________________________________________________________Axilla:_________________________________________________________________________Scapula:_______________________________________________________________________Other:________________________________________________________________________Things that worsen symptoms:Arms overheadStretch/danglingRunningVacuumingOther ________________________________________________Symptoms are:ConstantWith exertion onlyControlled with NothingNSAIDSNarcoticsOther _____________________Symptoms are:Getting worseGetting betterRelatively stablePrior therapy: PT: For TOSFor other diagnosis _______________________________________How long _______________ Outcome___________________________________________________Surgery?What_____________________________________________ when_________________ What_____________________________________________ when_________________What_____________________________________________ when_________________Outcome__________________________________________________Prior injury: PossibleProbable When? _______________________________________Describe:______________________________________________________________________ Possible repetitive trauma?_______________________________________________________________Occupation : __________________________________________ Retired DisabledRelevant avocation(s), sports: __________________________________________________________________ EXAM:Posture:NormalSlumpedSpontaneous arm use:Uses arm normallyFavors armHand atrophy:NonePresentNeurovascular exam at rest:Radial pulse normalAbsentNeuro exam normalAbnormal_________________________________________________Contralateral exam normalAbnormal __________________________________________________No swellingMild ModerateSevere swellingGrip normalWeakTinel’s Carpal tunnel negativePositiveCubital tunnel negativePositiveOther:__________________________________________________________________Supraclaviular:Tender MildModSevereReproduces distal symptomsSubcoracoid:Tender MildModSevereReproduces distal symptomsAxilla:Tender MildModSevereReproduces distal symptomsSpurling’sNegativePositiveRIGHTLEFTTesting:EASTNegativePositive at5 10 15 20 30 60 120 180 secondsReproduces distal sxs Describe:_________________________________________________________ULTT StraightNegativePositiveElbow bentNegativePositiveDescribe:_________________________________________________________OTHER DX:Spine disease_________________________________________________________________________Shoulder pathology____________________________________________________________________Carpal tunnel syndrome________________________________________________________________Ulnar nerve entrapment________________________________________________________________CRPS________________________________________________________________________________Brachial neuritis________________________________________________________________________Psychiatric diagnos(es)__________________________________________________________________Other ________________________________________________________________________________Possible opioid dependence Litigation Workman’s comp TESTING:Block:ReliefNo reliefDetails__________________________________________________________________CXR:NormalCervical ribLong C7Other ___________________________Grip strength _________ kgNCS:NormalMAC abnormalOther abnormal _________________________Arterial duplex:NormalAbnormal____________________________________________Venous duplex:NormalAbnormal____________________________________________SCALES:Quick DASH (0-100)_____Work (0-100) _____Sports/arts (0-100) _____CBSQ (0-120)_____Plus subjective informationTOS Disability scale:Normal/cured Fully disabled109876543210HIGHMEDIUMLOWLOWMEDIUMHIGHSUSPICION (Provider)SEVERITY (Patient)ASSESSMENT:Alternative diagnosis: __________________________________________________________________Also present:VTOSATOS______________________________________________PLAN:Diagnostic BlockAnterior scalenePec minorMiddle scalene SubclaviusTherapeutic blockAnterior scalenePec minorMiddle scalene SubclaviusPTDuration___________________________________Recheck in ____________ monthsOperationSupraclavicular/posterior FRRParaclavicular/total FRRTransaxillary/posterior FRRPosterior approachClaviculectomyPec minor excision/resectionBrachial plexus neurolysisOther_______________________________________Other:_______________________________________________________________________________ ................
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