Neck Injury
HISTORY:
Neck injury sustained ago
Onset: , following
Location:
Radiation:
Severity: , / 10
Type:
Pattern:
Worsening factors:
Treatments tried: ,
Occupation:
Other elements:
EXAM:
Cervical:
- Inspection:
- Palpation:
- Range of motion:
- Flexion:
- Strength: upper extremities -R /5 , -L /5
- Sensation: upper extremities -R , -L
- Reflexes: triceps -R , -L , biceps -R , -L , brachioradialis -R , -L
ASSESSMENT:
DDx:
PLAN:
- Cervical X-ray
- MRI of the cervical spine
- Advised that the condition is likely benign and that they should remain active as tolerated
- Encouraged to stretch, keep good posture, and avoid lifting weight
- Physical therapy
- Heat or cold therapy
-
-
-
- for
- Referral to orthopedic surgeon
- Referral to pain management specialist
- Follow-up in
- Return if pain worsens, if new symptoms develop such as fever or unexplained weight loss, or if symptoms do not improve with treatment