The history of the disease with osteochondrosis of the cervical and lumbar

The History of the disease in the cervical and lumbar osteochondrosis is of interest because it reflects all changes in the human body. So readers imagine this disease fully, we offer a full review of inpatient hospital records of the patient.

The history of the patient's disease with degenerative disc disease consists of the following features:

  • passport part with the contact information of the patient and place of residence;
  • patient's complaints
  • history;
  • study objective
  • data of clinical and instrumental studies.

let's explore each part in more detail.

the history of the disease in the degenerative disc disease

When entering the ward the patient complains of pain in the neck, dizziness, headaches, numbness of the upper extremity. When you try to turn your head to one side increases vertebrobasilar insufficiency. A similar clinical picture is observed when lifting weights.

At the time of inspection the person complains of aching pain in the fingers. When you try to bend the arm there is a radiating pain in the region of the left forearm.

When bending and turning your head severe headaches, you receive vestibular syndrome. The patient reports that he sees "flies" before the eyes.

history: pathology appeared after exposure of the neck muscles. The patient believes that the first symptoms appeared 4 years ago when he was working outside in the winter time of year. She proved dull pain in the cervical spine. After 5-6 months he began to feel tingling in his left hand, morning increased numbness in the upper extremities.

History of life

The Patient was born in the Moscow area in 1964, was the middle child in the family. Over the life of the diseases was not observed. Well I was in school, then served in the army. Works as an engineer in an industrial plant. Personal hygiene complies with.

Married at the age of 26. Together they raised 2 children. Their health condition is normal. The next of kin of degenerative-dystrophic diseases of the spine don't hurt.

sexually transmitted diseases, tuberculosis is denied. The infectious disease does not hurt.

Smoking and alcohol drinking denies.

Allergies to drugs can not be traced.

study Objective:

  1. the General condition is satisfactory;
  2. consciousness clear;
  3. active;
  4. normosthenic physique;
  5. weight 90 kg, height 180 cm
  6. body temperature is normal.
  7. the skin is pink, normal condition;
  8. on the skin is not marked pigmentation, hemorrhage, and rash;
  9. type of body hair meets a floor;
  10. the patient's nails the right shape; their surface is smooth, the signs of a fungal infection of the nail plate is not observed;
  11. subcutaneous fat are good;
  12. peripheral lymphatic nodes are not increased;
  13. muscular system moderately developed;
  14. bone-joint system has no deformation;
  15. moving the spine in extension and flexion, with the exception of pain in the cervical spine when tilting head forward.


A patient with degeneration of the lumbar and cervical spine allows you to identify the symptoms of the disease. Normal complexion is pink, but when disruption of the blood supply in the neck and he becomes pale.

The Palpebral fissure decrease in violation of innervation in spinal segments C1-C7. Through the cervical segments are nerves that are responsible for nervous impulses to the organs of the thorax, the vertebral artery and occipital muscles. At loss of the function of some nerves in humans there may be hoarseness, difficulty swallowing and breathing.

In this situation, if the examination of the chest there is an irregularity of intercostal spaces. Sometimes breathing becomes reinforced. In the study of under - and supraclavicular fossae can be observed their modest retraction.

chest Palpation

Chest Palpation in degeneration of the spinal column shows a stiff neck and intercostal spaces. Voice trembling in diseases of the vertebral column may not be symmetrical.

Percussion of the chest shows that the same areas of the chest cavity varies pulmonary sound. The signs described above are not direct manifestations of disease of the spine.

Degenerative diseases of the vertebral column are detected when performing radiography of the spine in frontal and lateral projections, tomography and magnetic resonance imaging.

In the presence of a painful syndrome on the background of lumbar osteochondrosis discomfort increases with pressure on the pathological region. These symptoms help to determine the place of infringement of the nerve roots.

The Assessment of the neurological status allows you to more carefully examine the spine in osteochondrosis and identify secondary signs of infringement of the nerve fibers.

In the study of neurological status able to examine the condition of the nervous and peripheralactivity. If the patient is steadily focused in space and time, it is obvious that in osteochondrosis of the cervical spine is not a serious infringement of the vertebral artery.

Sometimes the background of the disease appear the following neurological symptoms:

  • speech disorders
  • sternocleidomastoid head movements;
  • insomnia
  • difficulty performing complex goal-directed movements.

The Pathological symptoms greatly depend on the location of infringing on the nerves.

Osteochondrosis in the lumbar spine in humans, there are other clinical manifestations: positive Lasegue reflex, there is no full answer from the Achilles tendon.

Thus, the history of the disease with osteochondrosis of the lumbar and cervical spinal column consists of many minor manifestations of the disease. In their analysis, the doctor sets up not only the correct diagnosis, but also may involve further development of the disease.